Phone: and / or Mobile:
Confirm E-Mail:

How I heard about the Weight Loss Challenge:

I have spoken to a coach already about the weight loss challenge: No      Yes
If yes, please state the name of the coach:

Preferred class times:

Challenge choice:
5.30pm Tuesday - starting 16th January 2018
Daytime class by . Please tell us what times would suit you.

I have read, and accept, the Participation Agreement for the Community Weight Loss Challenge
No      Yes

Method of payment: internet deposit       bank deposit       cheque
(Further payment details will be provided upon submission of form.)

Any further comments: