Name Age
Member Number Date
Evening Phone
Day Phone
Cell Phone
Email

PERSONAL GOALS (check all that apply)
Economize Workout Time
Improve Posture
Injury Rehabilitation
Improve Flexibility
Improve Cardiovascular
Improve Motivation
Relieve Stress
Tone & Firm
Improve Strength
Gain/Lose Weight
Strengthen Bones
Sport Specific Training
Other

PREFERRED CLUB(S) (check all that apply)