BCS Fitness

* Name

* Best Time to Reach You

* Address

* City/State/Zip

* Home Phone

Mobile Phone

* Email

* Occupation

* Birth Date

* Gender

* Approximate Weight in lbs.

* Height

* Age

* Can you commit to exercising 4 days per week for the next 3 months? (two of those days being the 12 Week Challenge)

* Have you, at some point in the last 2 years, used strength conditioning equipment (i.e. free machine weights, etc) to exercise?

* What do you hope to accomplish in the 12 weeks that you are training with us?

* If one of your goals is to lose unwanted body fat, are you willing to adjust your daily eating habits?

* Are you aware of any personal health concerns that would limit your ability to participate in the 12 Week Challenge? (i.e., recent surgery, high blood pressure, diabetes, etc') If so, please explain:

How did you hear about us?

* Select your group dynamic preference:

* First Time Preference:

* Second Time Preference:

* If selected, I acknowledge that payment for the 12 Week Challenge in the amount of $405.00 (tax included) will be payable either in full or in three monthly installments of $135.00 (tax included) by the 2nd day of each month trained. New clients will also pay a one time $45 enrollment fee.

* I am interested in joining a Platinum 12 Week Challenge at an increased rate of $185 (tax included) per month.

If selected, I acknowledge that payment for the Platinum 12 Week Challenge in the amount of $555.00 (tax included) will be payable either in full or in three monthly installments of $185.00 (tax included) by the 2nd day of each month trained. New clients will also pay a one time $45 enrollment fee.

* Verify