TEXINS CHALLENGE - 6 Week Fitness Performance Program 2019 Question Title * 1. First Name: Question Title * 2. Last Name: Question Title * 3. Email Address Question Title * 4. Are you currently a TI employee? Yes No Question Title * 5. Are you a Texins Member? Yes No, but would like to join for this program Question Title * 6. Program Cost: $60 Texins Member; $170 Non- Member. Please select your payment option. $60 Texins Member, Payroll deduction (TI employees only).By selecting this option you are authorizing Texins to proceed with the $60 payroll deduction charge. $60 Texins Member, Credit Card. Please provide credit payment at the front desk at Texins Fitness Center by Tuesday July 9th $170 Non Texins Member, Payroll deduction (TI employees only). By selecting this option you are authorizing Texins to proceed with the $170 payroll deduction charge. $170 Non Texins Member, Credit Card. Please provide credit payment at the front desk at Texins Fitness Center by Tuesday July 9th Question Title * 7. Commitment is Key! The results you can expect from this program will reflect your commitment to the program. I will ensure that I will carry out the full program by attending both classes for the full six weeks. (Please sign below) Thank you for participating in the 2019 Texins Challenge! Done