Registration Form

Registration and Waiver

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Name *

First

Last

Email *

Address *

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City

State

Zip Code

Country

Phone Number *

1. What are your goals for this session? Fitness, health, lifestyle, specific distance or time, etc… *

2. What are your long term goals for fitness, health and/or lifestyle? *

3. What is your fitness background? What do you currently do for exercise? *

4. How did you hear about Keep Moving Mama? If it’s a friend, include her name so we can thank her. *

5. What do you hope to gain by joining? *

6. How many servings of fruits & vegetables do you eat each day? *

7. How many ounces of water? *

8. Anything else your trainer should know? *

Click here to read waiver. Once you are done, click the BACK button on your browser to return to this form.

I have read and agree to the waiver above. *

I agree

Once you click SUBMIT you'll receive a call from us within 24 hours.

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