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					                                                  Maximized Living Makeover
                                                August 28th – Registration Form
                                               Murray Arts Center 9AM – 12 PM
                    For assistance: Contact Charmaine Rhodes or call (770) 420-0492.

Name ___________________________________________________________________________

Street Address ____________________________________________________________________

City _________________________________ Zip Code _________________________________

Home # ___________________         Work # __________________ Cell # _____________________

The majority of the communication from Dr. Jockers and Maximized Living will come by email.

Email Address ____________________________________________________________________

Please note that by providing your email address, you will automatically receive Dr. Jockers’ health
bulletin approximately once per month through the year. You can opt out at any time.

How did you learn of Maximized Living?________________________________________________

Please name your referral source, if applicable! ___________________________________________

Help us help you! What have you already done to maximize your life?

                           Past      Present Details / Program / Provider
  Dietary Changes
  Alternative Medicine

If you are married or in a relationship, we strongly suggest you attend with your significant other.
Accountability groups are vital, so we give you the opportunity to register additional family members
at a special rate. Will anyone be attending the Program with you?

                                                    Yes No

Now that you have registered, you can expect to receive email announcements from our team. Please
check your email regularly and read all correspondence carefully. Check all folders, including your
bulk mail or junk mail folder, so you don’t miss anything. If you have any further questions, please
email us at

                                             PAGE 1 OF 2
 Registration Fees                           Primary Registration
                                            (with Resource Guide**)
 General Registration                                 $49
 Pre-Registration***                                  $29

* The “Additional Registration” fee is only available to immediate family members registering for this Seminar, and
to solo participants who already own the book “Maximized Living Nutrition Plans.” One book is recommended per

*** Pre-Registration Discounts are available only until 12:00 pm on Friday, August 27th 2010.

Group Registration: Contact our office for group rates (5 or more people, pre-registration

                       Name                                                             Fee
Registration # 1       ________________________________________                         _________________

Registration # 2       ________________________________________                          _________________

Registration # 3       ________________________________________                          _________________

Registration # 4       ________________________________________                          _________________

                                                      Total Registration Fee:            _________________

Payment by: (Circle One)

MasterCard      Visa      ______________________________________                        exp date __________

Cash Check (Please make cheques payable to Exodus Health Center)

Office Use Only -- Sign and date all that apply:

        Registration Received by __________________________                         Date _____________

        Payment Received by _____________________________                           Date _____________

        Visa/MC/Debit Processed by _______________________                          Date _____________

        Platinum Information Processed by __________________                        Date _____________

If you are completing this registration form at home, please fax the completed form to
(770) 420-0522, or deliver it in person to our office at 2750 Jiles Rd Suite 105 Kennesaw, Ga

                                                  PAGE 2 OF 2

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