Diabetic Devahs. ^{Choose It} and Lose It with me...the weight project that rewards

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Date:______________________   Referred by:_________________________________

NAME:    ___________________________________________         DATE OF BIRTH: ___________________________AGE:_______        __________________________              

ADDRESS: ______________________________________________________________________________________________________

TELEPHONE: ___________________________EMAIL ADDRESS: ________________________________CELL:__________________

MAILING  ADDRESS:____________________________________________________________________________________________________

IN CASE OF AN EMERGENCY, NOTIFY: _____________________________________  TELEPHONE NUMBER : ______________________

Commitment Fee:   YES: _______________  NO:___________________ (No: only entitles you to a gift certificate) 

Non-refundable Fee Received On:_________________________   Online: _______________  Store Location:______________________________    

Health Facility Name and Location _____________________________________________________   

Weight Loss Segment: 1)  January 12 - February 5, 2009   2)  February 9, 2009 - March 5, 2009   3) March 9, 2009 - April 3, 2009   4) April 6, 2009 – May 1, 2009  5) ALL                   Must participate in a minimum of 2 segments 

Weight Now: __________________  Weight Goal:__________________  Dress Size Now:_________________ Dress Size Goal: _________________

Health:  Diabetes              Cholesterol               High Blood Pressure               At "Risk"                    

Other: Please specify:

Limited to 20 Participants

Please consult your physician before beginning any weight loss program, project, or plan

ADDITIONAL INFORMATION

FUTURE GOALS: ________________________________________________________________________________

Suggestions: ______________________________________________________________________

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Contact me at: diabeticdevahs@galacar.com   

2640 Ceaery Blvd., Suite 11, Jacksonville, Fl 32211