AIOP Fitness Registration

Students Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

How did you hear about us?

Classes

Check all boxes that apply

Zumba

MixxedFit

Trampoline (Wednesday) [Limited to 10 people]

Trampoline (Saturday) [Limited to 10 people]

Name On Card

Card Number

Expiration Date

CVV#

Billing Zip Code

Email Receipt

(There is a annual $20 registration fee)

Yes

No