Please provide the following information: First Name * Last Name * Email * Re-Enter Email * Phone Number * Are you a member of the Wellness Center? Yes No Member Type? Western Student Western Staff Western Retiree Western Alumni Western Community Member Western Spouse What days/time of the week work best for you? Check all that apply Monday (am) Monday (pm) Tuesday (am) Tuesday (pm) Wednesday (am) Wednesday (pm) Thursday (am) Thursday (pm) Friday (am) Friday (pm) Trainer Preference Trainer Preference (Note that we have a limited amount of personal trainers, but will do our best to accommodate your needs. If the trainer is available during you preferred time, you will be assigned to that trainer.) Male Female No Preference Services you are interested in? Check all that apply Free Consultation Body Comp Test One-on-One Training Fitness Assessment Partner Training Nutrition Coaching Session Any/All Other Leave this field blank