Maximized Living Makeover
August 28th – Registration Form
Murray Arts Center 9AM – 12 PM
For assistance: Contact Charmaine Rhodes or call (770) 420-0492.
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
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?
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 firstname.lastname@example.org.
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Registration Fees Primary Registration
(with Resource Guide**)
General Registration $49
* 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
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
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