12 Weeks to Weight Loss & Wellness Fall Session '09

Registration Form

To register for the 2010 Fall Session, please provide the following information:
* An asterix indicates a requred field that must be filled in order for the form to work



* First Name:
* Last Name:
* Email:
Street Address:
City:
* Home Phone #
( )
Bus. Phone #
( )

Choose a program:
Basic
Program:
$395.00
$395.00
$395.00
$395.00
Optional
Nutritional
Counseling:
$130.00
$130.00
N/A
N/A
Optional
Fitness
Training:
$100.00
N/A
$100.00
N/A
Subtotal:
$625.00
$525.00
$495.00
$395.00
5% GST:
$31.25
$26.25
$24.75
$19.75

Total:

$656.25

$551.25

$519.75

$414.75

 

If paying by cheque, please make payable to
"Wholly Hannah! Coaching and Training" and mail to:
7502-155 Street, Edmonton AB T5R 1V6

If paying by credit card, please call Claudette at
780-481-0313 to provide information.

(Information gathered on this form will be kept confidential and will not be used for solicitation purposes.)