First Name _______________________________________________________
Middle___________________________________________________________
Last Name________________________________________________________
Address__________________________________________________________
City________________________State_________Country__________________
Zip/Postal Code_________________Home Phone________________________
Work Phone________________________E-mail__________________________
Age________Sex______Height______Occupation________________________
Interests__________________________________________________________
_________________________________________________________________
Membership option: PLAT $59________ GOLD $29 ____________ SLVR $19 __________
(Your Gym) Name___________________________________________________
Address___________________________________________________________
City________________________State__________Zip/Postal Code___________
Phone Number_______________________E-mail_________________________
Send all payments directly to:
NDFAA
Tina Thompson Dance Fitness
48 Studio Lane
Staten Island, NY 10304
Made payable to: Tina Thompson
Memo: membership