Membership Application

Member Information

The application process takes approximately 20 minutes to complete. Please take your time when filling out the application and be as thorough as possibly in your answers. This information is intended for trainers and support staff and is the basis of your approval into the program.
Applicants will receive notice within 24 hours of submitting the application of membership approval.
Payment for the challenge is due at time of application. Applicants that are not selected for participation in the program will receive a refund of the contestant fee immediately.

Formatted Text

Are you a: *

New Contestant

Returning Contestant

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Current Weight *

Height *

Age *

Date of Birth *

Emergency Contact Person (and relationship) *

Phone Number *

Please list your current medications and what they are taken for. *

Do you use tobacco? *

We love to give credit when credit is due, so please let us know how you heard about the challenge! *

Would you like to receive news from our sponsors? (upcoming events, information, specials, discounts, etc.)

	Please check the appropiate box.
Yes	Please check the appropiate box.
No	Please check the appropiate box.