Enrollment Form

Send completed forms to: Mobile Fitness, 49 Dartmouth St., Portland, ME 04101

Class Name: ________________________Day and Time____________________

Class NAme:________________________Day and Time____________________

Class Name: ________________________Day and Time____________________

Start Date of Class(es) : _____/_____/_____ PRICE$____________________

Personal Information:

Name: __________________________________

Date of Birth: ______/______/______ Age_________

Billing Address: street________________________________________

city________________________zip code___________

Home Phone: _________________ Cell Phone ________________

Receive our newsletter for current class schedules!!

Email Address : __________________________________

PAYMENT OPTIONS

Check No._____________

Credit Card #________________________Exp. Date__/__ 3 digit SEC#____

Visa/Mastercard ONLY

PLEASE READ:

I understand I am purchasing group exercise class(es) from Mobile Fitness, not an individual Trainer. Since spaces in each class are limited and must be reserved, I understand I will not receive a refund for any classes which I miss. I agree that if payment is made by credit/debit card, I authorize Mobile Fitness to charge my account for each class I enroll in.

Signature: Date: