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There is a non-refundable fee of $195 (must be received before we process application)

Enrollment Application

First Name *

Last Name *

Date of Birth * (mm/dd/yyyy)

Gender *

Street Address *

City *

State *

Zip *

Email Address *

Cell Phone * (xxx-xxx-xxxx)

Day Phone (xxx-xxx-xxxx)

Evening Phone (xxx-xxx-xxxx)

Program/Location Selection

Program Requested *

Location Requested *

Weekend Group Requested *

Education and Employment

School Attended (1)

Address

School Attended (2)

Address

Current Employer

Employer Address

Position

Employer Phone

Why are you interested in the health and fitness field? *

What certifications do you currently have? *

References

Please include at least 3 personal references

Reference Name (1) *	Reference Address (1) *	Phone (1)* (xxx-xxx-xxxx)
Reference Name (2) *	Reference Address (2) *	Phone (2)* (xxx-xxx-xxxx)
Reference Name (3) *	Reference Address (3) *	Phone (3)* (xxx-xxx-xxxx)
Reference Name (4)	Reference Address (4)	Phone (4) (xxx-xxx-xxxx)
Reference Name (5)	Reference Address (5)	Phone (5) (xxx-xxx-xxxx)

Information on this application is true and accurate; falsification of any information will result in rejection of admission to the school or dismissal after enrollment.

Signature *

Date *