First Name
Last Name
Address
City/State
Phone
Email
Select Which Class You Will Attend:
Wednesdays, 7:30 p.m.. Class at Fitness Systems* (Space Available.)
Thursdays, 7:30 p.m. Class at Fitness Systems* (This Class is Full.)
Where did you hear about the class?
Please Specify:
Payment Form: .
Card Type: (MC, Visa, Discover, AE)
Number of Registrants:
First Name on Card*


Last Name of Card*


Card Number*


Security Code*


Expiration on Card (Month/Year)


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Weight Loss Challenge Registration                    All fields required
Your card will be billed $39 for each registration purchased by Serenity Enterprises.
Zip
* (Please note: You do not have to be a member of Fitness Systems Health Club
to participate.)