Extreme Makeover Challenge Registration

Last Name                                                 First Name                                     Middle Initial

Address                                                     City                         State             Zip

Phone Number                                                   Email Address

Registration Type: 

□  Cost  Includes Extreme Makeover Book, Online Audio Mentoring Resources & Recipes       

□ T-Shirt Size:

   □ S               □ M                  □ L                   □ XL                 □XXL               □XXXL

Payment Method:

□ Cash

 □ Check (Make payable to Abundant Life Wellness Center

 □ CREDIT CARD - MasterCard / Visa / AMEX / Discover

 Credit Card Number ___________________________________   Expiration Date _____________