Registration Form
90 Day Wellness Challenge
Complete this form to register for the Wellness 90 Day Challenge.

NOTE: The registration fee for new participants is $175.00 plus GST. You will
receive a confirmation email with instructions for payment when you submit
your registration form.
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Name:
Last
First
Address:
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Work Phone:
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Home Phone
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Email
Gender
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Age
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Weight*
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Height (feet)*
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Height (inches)*
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Please set a range for your 10-week weight loss goal (examples: 0-5 lbs, 5-10 lbs, etc.)
Remember to be realistic!*

Are you physically active?*
No
Yes

If you are physically active, please answer these three questions:
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Number of days per week you are active:

Number of minutes per day you are active:

Type of activity (walking, biking, etc.)

Please list all medications and supplements (prescription and non-prescription):

Please circle classes that you would be interested in attending.
 Zumba
 Boxing
 Belly dancing
 Yoga
 Mediation
 Pilates
 Line dancing class
 Laughing master session
 Cooking class
 Nutrition class
 Clean eating sessions
 Menu planning & recipe exchanges
 Resistance training
 Spiritual wellness
 Hypnos therapy session September
 Hula hooping
 Let's dance class
 Boot camp
 Running class
 AB training
 Running
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Other promotions to come:
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Free food samples
Potluck with recipe and ingredients
Vision boards session
Massage discount
Monthly prizes
Goal setting 90 days 180 days etc
8th must be pre-booked

There will be several classes offered at the Belle Petroleum Centre for you to attend at
your own discretion. Please check which times and day’s work best for you and your
schedule: Please note majority votes will be the chosen times & days (one hour classes
or sessions).
Please circle 3 times only:

Monday
noon
4 pm
7 pm
Tuesday
noon
4 pm
7 pm
Wednesday
noon
4 pm
7 pm
Thursday
noon
4 pm
7 pm
Friday
noon
4 pm
7 pm
Saturday
noon
4 pm
7 pm
Sunday
noon
4 pm
7 pm
What day of the week works best for you to attend weigh in, take measurements, and
meet with a team member?*
Thursday afternoon
No
Thursday evening
Monday afternoon
Yes
How did you hear about the wellness challenge?*
Web site
newspaper
Co-worker or friend
Facebook
Friend
In the Loop
Email
Spouse
Other

If applicable, please tell us who referred you so we can thank them!

Please read and accept the Wellness Challenge terms & conditions.
As a new participant in the Wellness program, I have read and understand the program
description, which includes, but is not limited to, the following.
What to Expect:

A lifestyle challenge that gives you the tools to lose weight, lose inches and new forms
of exercise for the body, mind and soul.
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Clean eating lifestyle training
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Group support for your weight loss & self-esteem & exercise goals
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Weekly weigh-ins and educational sessions
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A meal pattern calculated just for you (includes a daily calorie level and general outline
for how many foods to eat from each food group)
What Not to Expect:

A quick fix
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A recommended meal plan – you will have the flexibility to decide what specific foods to
eat each day
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Daily menus that take the “guesswork” out of losing weight – you will decide when and
what to eat throughout the day and adapt the meal patterns.
I agree to carefully follow the meal plan and dietary recommendations set forth in the
Wellness Challenge program. I am aware that failing to provide the Wellness team with
adequate information on any and all medical conditions will impair their ability to advise
me properly.
Please provide a doctor’s note giving you the ok to participate in this
program.
*
I __________________ have read the outline of this registration and agree that this is a
lifestyle change I am responsible for the results and will keep in touch with my family
doctor.
Please list your current medical conditions:
I agree
signature
Dr. Name
**
phone #
I __________________ have understand that this is Wellness challenge that is
promoted by local volunteer instructions and the Belle Petroleum Centre (Belle Marketing
Agency Corp. ) will not be held responsible for any liability related to this program or
event.
I agree
Payment received:
Signature Date: