Move.Laugh.Connect. Registration Questionnaire

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* 1. Contact Information

First & Last Name

Email Address

Daytime Phone Number

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* 2. How do you prefer to be contacted?

Email

Phone

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* 3. Are you a Cooper Fitness Center member?

Yes

No

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* 4. Select the Move.Laugh.Connect. class(es) you're registering for.

MLC MOVE

MLC Cycle

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* 5. Date of Birth

Date

Date

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* 6. Age

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* 7. Sex

Male

Female

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* 8. Emergency Contact

Name

Phone Number

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* 9. Personal Physician

Name

Phone Number