Please fill out the survey below if you would like to receive an additional $150 rebate  of your membership dues with your insurance or HMO.  This survey will allow us to learn more about your needs, and to see how much money you will save.


Please right click, "Select all",  then right click "Copy", then "Paste" into and fill out in  HorshamFitnessClub@gmail.com

                                      PRE-REGISTRATION

Your e-mail response should include the following:
NAME:
ADDRESS:
CITY, STATE, ZIP CODE:
PHONE #:
E-MAIL  ADDRESS:
WHERE DO YOU WORK?

HOW DID YOU HEAR ABOUT US?
HOW MUCH WEIGHT WOULD YOU LIKE TO LOSE?
BY WHAT DATE?

1- HOW OFTEN ARE YOU INTERESTED IN WORKING OUT?
      _1     _2     _3     _4+ days week 

WE OFFER SPINNING CLASSES EVERY DAY !!!  PERSONAL TRAINING, SEMI PRIVATE OR PRIVATE, ONE ON ONE PILATES OR YOGA ARE AVAILABLE  7 DAYS A WEEK. 

2- WHICH OF THE FOLLOWING SERVICES ARE YOU INTERESTED IN?

__MASSAGE                                __PERSONAL TRAINING  
__EXERCISE                                __DIET & NUTRITION COUNSELING
 __FLEXIBILITY                            __MEDITATION 
 __STRESS RELIEF                      __WOMEN'S HEALTH
 __BODY SCULPTING                   __ANTI-AGING FITNESS             
__LOSE WEIGHT                         
 __LOSE INCHES  
     
__BUFF BRIDES                          __QUICK START 
__FITNESS MAKEOVER             __  ULTIMATE WEIGHT LOSS
__FAT BURNING, HIGH INTENSITY, BODY CHANGING BOOT CAMP

3- DO YOU HAVE HEALTH INSURANCE?

__AETNA HMO / PPO              __KEYSTONE HMO
__PERSONAL CHOICE            __AMERIHEALTH
__BLUE CROSS                      __UNITED
__HIGHMARK / BLUE SH.        __CAR ACCIDENT
__CIGNA                                 __WORK COMP
__OTHER                                __NO INSURANCE 

 
          Darien Johnson - Operations Manager         HorshamFitnessClub@gmail.com          
           215 443-8510                                                217 Witmer Road, Horsham, PA