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First Name |
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Home Phone |
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Last Name |
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Work Phone |
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Address |
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Cell Phone |
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Town |
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State |
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Zip |
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Days & Times |
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Tues 8:00-9:30am |
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Wed 6:30 -8:00pm |
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Friday 7:30-9:00am |
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Signature |
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Birth Date |
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Level |
o2.5 o3.0 o3.5 o4.0 o4.5 |
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Payment |
oCheck oCash oCredit Card |
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Notes |
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x |
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o |
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o |
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o |
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Date |
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Days |
Times |
Member Price |
Non-Member Price |
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Tuesday |
8:00-9:30am |
$150.00 |
$200.00 |
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Wednesday |
6:30 - 8:00 pm |
$150.00 |
$200.00 |
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Friday |
7:30-9:00am |
$150.00 |
$200.00 |