Registration Form                                                                             DATE:_________

Name:_____________________________________________________________

Address____________________________________________________________

City______________________ State____________________ Zip ____________

Phone Number:

Home: ______________________________

Work: _______________________________            Email_____________________

Cellular: _____________________________

 

I will be paying: $ _________ per time monthly annually  

I will be paying by:

□ Check

□ Cash

Credit Card - Visa   MasterCard   Amex

Account Number □-□□-□□-□

Expiration Date /

3 Digit security code (on back of card)

I authorize Aliya to charge my credit card        

Signature:_________________________________

 

How many days of the week do you wish to come to gym? __________________

What hours do you plan to be at the gym? 

From: ________Till:__________