REGISTRATION FORM print and mail -

                                                                                                      
 Name:____________________________________

Address: _________________________________

 _________________________________________

City:______________________________________

Zip:_______________________________________

Phone: (H) _________________________________

                    (W)__________________________________

E-mail: ____________________________________

Check (x) if this is a NEW Address_____

Class # ______  

I am____am not____ a new student of Sheila's FitnessJAM

Check (x) if you need babysitting______ 

MC/Visa :   Acct #___________________________

                                     Exp. date_________________________

Signature:___________________________________

Please Make Checks Payable to:   SheilasFitnessJAM

                                                                                           378 Harris Hill Road

                                                                                               Williamsville, NY 14221

Sheila M. Samson-Powers

Independent Distributor

Market America,Inc

www.marketamerica.com/sheilasfitnessjam