Personal Fitness Training Program

Online Application for Admission

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PERSONAL DATA


First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Home Phone:
Work Phone:
Birth Date - mm/dd/yy
Social Security #:
Citizenship:

PROGRAM

Select the program you are applying for from the list below.

No records returned.

EDUCATION

List educational institutions attended with the most recent first. Official transcripts MUST be submitted before a Certificate will be granted.


School Name 1:
City/State:
Dates From/To:
Degree Earned:
School Name 2:
City/State:
Dates From/To:
Degree Earned:

EMPLOYMENT:

List current or most recent employment.


Employer
Address
City/State:
Phone
Job Description:
Dates Employed:

HEALTH RECORD:


Have you had any contagious diseases in the past 2 years? No Yes
If yes, please explain.
Do you have any health related issues the school should be aware of? No Yes
If yes, please explain.

REFERENCES:


Reference #1
Name:
Address
City:
State:
Phone:
Relationship
Reference #2
Name:
Address
City:
State:
Phone:
Relationship

OTHER:


Have you ever been convicted of a felony? No Yes
If yes, please explain.

How did you hear about us?
Other (please specify):

CERTIFICATION:

Type your full name in the space below to indicate that you believe the information provided above is true and complete.


Your Full Name:

PAYMENT:

Provide your charge card information for the $75.00 registration fee. The $75.00 registration fee is refundable prior to the first day of class.

Note: The registration fee for Florida is $50.00 and is non-refundable.


Email Address:
Name on Card:
Credit Card Data:
Credit Card #:

If you want a copy of this page for your records, print it now before you submit the page. Click on the Submit button just once. Depending on Internet traffic and server load it may take up to one minute for the order to be processed. However, if nothing seems to be happening, feel free to click again. You will not be billed twice.