Program Registration (Online payment below)

First & Last name:

Street Address::

City::

Postal Code: :

Phone number :

Email address:

Location/Program:
Boot Camp Mon/Wed Evening 6:30-7:30 Norm Hill Park
Boot Camp Tues/Th Wilmot Rec Centre 6-7am
BootCamp M/W/F at Dearborn 6 am
M/W/F 9:15-10:00 am at Kick'n Sport in New Hamburg
Mon/Wed/Fri 3-4 pm at Kick'n sport New Hamburg

Which program package?:
4 week program
6 month Boot Camp program
Bridal Boot Camp
Hopper Passes

I recruited a camper for the 6 month special:
yes
no

If yes...their name is:

If yes...their name(s) is/are:

Any medical conditions we should be aware of? :
yes
no

Emergency Contact: :

Emergency contact phone number: :

Method of payment: :
Cash (due on start date)
Cheque (due on start date)
Online (Visa, M/C, Amex, Paypal)

Any Gift Certificates or discounts applicable? (describe) :

How did you hear about Energy for Life Fitness programs?:

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