REGISTER

First Name *

Last Name *

Address *

City *

State *

Postal code *

Email *

Phone *

Date of birth *

T-Shirt Size *

Are you cleared by a physician to start a workout regime? *

Yes

Health and Wellness Fund Provider *

Please enter your Credit Card information. You will not be billed until you are notified that your access has been granted.

Complete Credit Card Number *

Expiration Date *

CVC *

Payment Authorization *

I understand that I am responsible for a $10.00 monthly payment to Empowering Punch to remain enrolled in the Workplace Wellness program presented by CB&T. Delinquent payments will result in suspension of access and possible removal from the program until resolved. I hereby authorize Empowering Punch to initiate automatic charges to my credit or debit card provided.

By checking this box, I agree that I have read the Disclaimer of Liability and Release of Claims for Empowering Punch, LLC, fully understand its terms, and agree to the terms stated freely and voluntarily without any inducement.

Wellness Program Opt-In *

By submitting my application, I understand I am enrolling in the workplace wellness program provided by Empowering Punch Fitness. I understand my personal contact information will only be used for health/fitness related communication and will never be shared or sold.

I Want to Participate in the Free Fitness Challenge *

Weight *

Referral *

Have questions? We're here to help.