* 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
    *