One-Day Tri Clinic Registration 2007

(to print, right-click this page and select print)
   
Please make checks payable to: Lifetime Fitness
Please circle the following clinic date you'd like to attend: January 28, 2007  

or

March 11, 2007

 
Mail registration form and payment to:
LJ White
13606 Yellow Poplar Dr.
Centreville, VA  20120

NAME

LAST NAME

 

 FIRST NAME
STREET

 

 CITY STATE ZIP
HOME PHONE

 

 CELL PHONE
EMERGENCY CONTACT

 

 EMERGENCY PHONE
E-MAIL ADDRESS 

 

 $125 registration fee for Lifetime Member             or            $145 Non-Lifetime members
  Please sign and date below
   
  X_____________________________________________________________________________________
  Signature Date