Maximized Living Makeover

Jan 15th – Registration Form

North Metro Church 9AM – 12 PM

For assistance: Contact Lisa Gageor Charmaine Rhodes bycalling (770) 420-0492.

Name ______

Street Address ______

City ______Zip Code ______

Home # ______Work # ______Cell # ______

The majority of the communication from Dr. Jockers and Maximized Living will come by email.

Email Address ______

Please note that by providing your email address, you will automatically receive Dr. Jockers’ health bulletin approximately once per week through the year. You can opt out at any time.

How did you learn of Maximized Living?______

Please name your referral source, if applicable! ______

Help us help you! What have you already done to maximize your life?

Past / Present / Details / Program / Provider
Dietary Changes
Vitamins/Detox
Exercise
Chiropractic
Alternative Medicine

If you are married or in a relationship, we strongly suggest you attend with your significant other. Accountability groups are vital, so we give you the opportunity to register additional family members at a special rate. Will anyone be attending the Program with you?

Yes No

Now that you have registered, you can expect to receive email announcements from our team. Please check your email regularly and read all correspondence carefully. Check all folders, including your bulk mail or junk mail folder, so you don’t miss anything. If you have any further questions, please email us at .

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Registration Fees / Primary Registration
(with Resource Guide**)
General Registration / $49
Pre-Registration*** / $29

* The “Additional Registration” fee is only available to immediate family members registering for this Seminar, and to solo participants who already own the book “Maximized Living Nutrition Plans.” One book is recommended per family.

*** Pre-Registration Discounts are available only until 12:00 pm on Friday, Jan 14th2010.

Group Registration: Contact our office for group rates (5 or more people, pre-registration only).

NameFee

Registration # 1______

Registration # 2______

Registration # 3______

Registration # 4______

Total Registration Fee: ______

Payment by: (Circle One)

MasterCard Visa ______exp date ______

Cash Check (Please make cheques payable to Exodus Health Center)

Office Use Only -- Sign and date all that apply:

Registration Received by ______Date ______

Payment Received by ______Date ______

Visa/MC/Debit Processed by ______Date ______

Platinum Information Processed by ______Date ______

If you are completing this registration form at home, please fax the completed form to

(770) 420-0522, or deliver it in person to our office at 2750 Jiles Rd Suite 105 Kennesaw, Ga 30144

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