Heart Healthy Registration

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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

Your Donation