First & Last Name  
Address  
   
City  
State  
Zip Code  
     
Email Address  
Daytime Phone  
Evening Phone  
     

Name of Friends/Family You Would Like To Get Fit With:

 
How much time will you be devoting to a healthier lifestyle per week?
 
Is your family supportive of your desire to improve your well being?
Yes    No
 
Would an improvement in your health affect your family?

Yes    No
If yes, how? 

 
What are you looking for in a fitness facility?
 
What areas of your body would you like to focus on?
Waist   Hips   Thighs   Chest   Arms   Glutes
 
On a scale from 1 to 10 (10 being most important), please rate the following:
Safety     1   2   3   4   5   6   7   8   9   10
24 hr Access    1   2   3   4   5   6   7   8   9   10
Sunday Access    1   2   3   4   5   6   7   8   9   10
New Equipment   1   2   3   4   5   6   7   8   9   10
Personal Trainer     1   2   3   4   5   6   7   8   9   10

Shower Facilities

   1   2   3   4   5   6   7   8   9   10
 
Any additional comments you would like to add?