Heart Healthy Registration

Name*

First Last

Age*

Phone*

Email*

What are your current fitness goals?*

What do you believe are your biggest obstacles in reaching your goal?*

Current Fitness Level*

Beginner: Little to no exercise or gym experience. This is for individuals just beginning their fitness journey. Intermediate: Moderate experience level with exercise and gym equipment. For most who have some sort of fitness background Advanced: Above average experience with exercise and gym equipment. For individuals ready to #WORK

On a scale from 1 (poor) – 5 (great) describe your current eating habits.*

Interested in learning about meal plan options and how to eat healthier?*

Facebook Profile Name*

You will be added to the #WORK Heart Healthy group page where you will receive important updates as the competition progresses.

Your Donation

Dinez Merrao would like to thank you for your contribution towards the #WORK Heart Healthy Challenge Fundraiser. We can use this month to raise awareness about heart disease and how people can prevent it. One way is through exercise. A percentage of your purchase will be donated towards raising awareness about women and heart disease.

Heart Healthy Challenge Donation*

Price: $25.00

Heart Healthy T-Shirt Donation*

Percentage of sales profits will be donated to local heart disease organizations.

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Total

$0.00