LIFE STYLE CHANGE NETWORK
Boot Camp Registration Form
State*:
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Home Phone:
Age:
Does a physician regularly see you? Yes No
When was your last doctor's appointment? -- Month -- January February March April May June July August September October November December -- Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Doctor's name, address and phone number?
Have you ever been enrolled in a weight management program before? Yes No If yes, where and when?
In case of emergency who should be contacted? Provide Name, Address & Phone#
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If you have any questions please call (410) 254-1555 Totally You, LLC
Saturdays 9:45am & 11am
Wednesdays 7:30pm
Friends and Family Day
Divine Worship/WC
