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*indicates required fields

*First Name:

*Last Name:

*Street Address:

*City/Zip Code:

*Email:

*Main Phone:

*Alternate Phone:

*Male/Female:

Male
Female

*Age:

*BootCamp Group Selection:

Group 1 - M/W/F, 6:30 AM
Group 2 - FULL
Group 3 - M/W/F, 9:00 AM
Group 4 - M/W, 5:00 PM, Sat 9:00 AM
Group 5 - M/W, 6:00 PM, Sat 10:00 AM
Group 6 - M/W, 7:00 PM, Sat 11:00AM
Group 7 - T/TH, 6:00 PM, Sat 12:00 PM
"At Home" Option - No Classes or Gym Membership $75

*Payment:

Credit Card Payment Now
Credit Card (at West Park Station)
Cash (at West Park Station)
Cash (at Anytime Fitness)
Check (at West Park Station)
Check (at Anytime Fitness)

Credit Card # (16 digits):

Credit Card Expiration (xx/xxxx):

Name on Card:

*How did you hear about this Challenge?:

*T-Shirt Size (men's sizes):

SM
MED
LG
XL
XXL

Comments:

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