* Indicates required fields


GENERAL INFORMATION
   
Last Name *
First Name *

Middle Initial

Maiden Name (if Applicable)

   
Street Address *

City *


State *
Country (if other than U.S.)

Zip Code *

E-mail Address *

Phone *
Day

Evening
The best time to call me is


PERSONAL
Date of Birth

/ /
MM/DD/YYYY
Driver's License Number
   
Gender:
 Male   
  Female
 


EDUCATION
I have graduated from
high school:
Yes
No
I am planning to graduate
from high school:
Yes
No
I have received a GED certificate:
Yes
No
I am expecting to receive a GED certificate:
Yes
No
If Yes,
Month/Year
/
MM/YYYY
If Yes,
Month/Year
/

MM/YYYY
If Yes,
Month/Year
/

MM/YYYY
If Yes,
Month/Year
/
MM/YYYY
Name of High School

City


State

Name As It Appears on High School Academic Records


Have you applied to THIS institution before?
Yes
No
If yes, for which year?


(YYYY)

Have you attended college before?
Yes
No

If you have attended college, approximately how long did you attend?
Less than 1
year
1-2
years
2-3
years
3-4
years

Degree Received?
Yes
No

Extracurricular Activities (such as community or school involvement)



EMPLOYMENT

Current Employer

Position


Duties



Please describe your current work schedule:




GYM MEMBERSHIP
Are you currently a member at a gym?
Yes
No
If so,
What is the name of the gym?
What is the Managers name (if you know it)?
What is the phone number at the gym (if you know it)?
Please describe your current level of fitness activity?
Please describe your anticipated level of support from friends and family:


FINANCIAL
Have you set money aside for your education?
Yes
No

  Method of Payment

I will pay for my entire term charges on or before registration.
I will provide a letter from an authorized company or agency confirming that it will pay my entire charges each term.
I will require financial assistance to help pay my term charges. If necessary, my  
co-borrower will be:  



Are you a U.S. citizen?
Yes
No


How you heard about Personal Fitness Trainer Associate
*