Registration Form

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This form is only for online payments.

If you would like to make payment by debit, cash or cheque, please contact the Be Fit For Life Centre at 780-539-2816.

Participant Information

* First Name
* Last Name
* Address
* City
* Province
* Country
* Postal Code
* Gender	Male Female
* Date of Birth
* Home Phone
* Work Phone
* E-Mail
Fax

Challenge Category (your age as of Jan 1, 2009)

	Description	Cost

Couples Challenge

I am registering for the couples challenge (+$45).

* The additional $45 fee is per couple, not per individual. Only 1 person is required to pay the Friends & Family fee, however BOTH people are required to register individually into their appropriate individual category.

What is your partner's name?

How did you hear about us?

	Word of mouth
	Newspaper	If so, which paper?
	Radio	If so, which station?
	Television	If so, which station?
	Poster	If so, where was it?
	Tradeshow	If so, what tradeshow?
	Referred	If so, by who?

Extra Information / Comments

If you have any medical conditions or special needs that you feel we should know about, please specify them here:

Registraton Terms & Conditions - Read Carefully

A $20 fee will be charged for missed appointments or if at least 24 hours notice is not given when changing your testing appointment. Participants will be issued a refund only for medical reasons, otherwise fees paid are not refundable.