Legal Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

IFC Member *

Yes

No

Permission *

By signing up for this class I am giving permission that my any results and other pertinent Protected Health Information can be shared to me by way of the email that I am registering under. This holds for both if signing as a couple.

Yes, I give permission

Name #2

second person if couple rate

First Name

Last Name

Date of Birth

MM

DD

YYYY

IFC Member

Yes

No