Enrollment Form for Kinship Wellness Challenge 2007 - Printable Form

First Name_____________________  Last Name:  ____________________________________

How you want your name to appear on the Web Site:  _________________________________

Street:  _______________________________________________________________________

City:  _____________________________  State:  ____________  Zip:  ____________________

Phone:  __________________________  What is your goal:  ____________________________

Comment Line:  (e.g. start weight, personal comment) _______________________________________

______________________________________________________________________________

Email Address:  _________________________________________________________________

T-Shirt Size:    S       M      L       XL     XXL  (circle)

Mail to:  Kinship Partners                                        

             910 Pine Street
             PO Box 642
             Brainerd, MN 56401

Enclose a check for $30.00 Payable to "Kinship Partners"

Please contact me about being a Kinship mentor:  _________________