Full Reg. Form

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Full Registration Form

If you don't have a HealthyClub Member Number, you have to fill out and submit the following form to register yourself as a member of the HealthyClub. There is a one time $15 member fee and $3 processing fee. Without it, we can't process your application.

You may also use this form to update your member information.

Screen Information

Create your HealthyClub User Name
<-- The name to be viewed in HealthyClub.
Choose your Password:

Re-enter your Password again for verification:
<-- Make sure it's the same as Password.

Personal Information
This information will helps us to better understand the types of people who use HealthyClub, and to better serve our HealthyMember.  The information you provided here will be used exclusively by HealthyNest and will not be disclosed to any third party.
Required:
Your First Name: Your Last Name:
Gender: Location:
Email Address:
Phone Number:* - Fax Number:* -
*Please include your area code and country code, thanks.
Your Birthday:      Month     Day
  Yes, I would like to receive further newsletter from HealthyNest.
Optional:
Occupation:

Company:
In case you forget your password
If you forget your password, you'll be asked a questions you specified below. We'll send you a new password to the email address you provide above, so make sure it is correct.
Your Question:
Your Answer:
Is this new registration or an update of your membership: 
Please select:
If this is an update, please include your card's number on the back of your member card
Your card number: --


 

Please note:

There is a one time $15 member fee and $3 processing fee. Without it, we can't process your application.

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Last modified: October 05, 2004