Enroll

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Thanks for your interest in Energy Krazed. If you are interested in enrolling or if you would like to enroll a child, patient, or student in our 9-week program, please fill out the form below and we will be in touch as soon as possible. If you are under 18, please have a parent help you fill out the form.

Enroll

If you are human, leave this field blank.

Enrollee Contact Information

Enrollee Name *

Guardian Name (if under 18) *

Date of Birth *

Gender *

Best Contact Email *

Phone *

Address *

Enrollee Physical Fitness Profile

We will use this information to determine if you are eligible for the program.

Height (inches) *

Weight (pounds) *

Are you making a referral?

Are you filling out this form on behalf of someone else (e.g. a child or patient)? *

yes

Referrer Contact Information

Your Name *

Relationship to Enrollee *

Email *

Phone *

Authorization

By typing my full name below, I give my permission to the referring person to release my information to Energy Krazed. *

By typing my full name below, I agree that this information is to be used to assist me in monitoring and coordinating my health needs. *

Please briefly indicate why you or the person you are referring would like to participate in Energy Krazed. *

Enrollee Contact Information

Enrollee Physical Fitness Profile

Are you making a referral?

Referrer Contact Information

Authorization

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