Name *

First Name

Last Name

Phone *

(###)

###

####

Are you in? *

Yes! Count me in for the 75-Day Health & Fitness Challenge

Awesome! What health or fitness plan will you practice for this 75-Day Challenge? *

Check all that apply

The diet/nutrition plan of my choosing

Walking a minimum of 7,500 steps per day

The exercise plan of my choosing

Daily stretching, yoga, and/or meditation

Abstinence from certain foods or drinks (ex. sugar, alcohol)

Biking 7.5 miles per day

Running 7.5 miles per week

75 jumping jacks per day

75 steps during every waking hour

Other (is there another fitness activity you choose?)

If you selected "no" or "not sure" above, what is the mailing address where we can send your certificate of completion?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country