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Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Please Select The Following That Apply To You *

*Eligibility for Special Pricing Discounts*

Student (Current)

Military / Veteran

Military Dependent / Spouse

Healthcare Professional

None of the Above

Does Your Occupation Require Much Activity? *

Yes

No

Sometimes

In the past 6 months, how often have you been engaged in physical activity? *

Very Often: 4-6x / Week

Often: 2-4x / Week

Less Often: 1-2x / Week

Not Often: 0x / Week

What types of aerobic training modalities interest you?

Walking

Cycling / Stationary Bike

Elliptical

Swimming

Jogging

Hiking / Stair Climbing