Pacificwide: 2018 Weight Loss and Fitness Contest Registration
Looking to enter Pacificwide's 2018 Weight Loss and Fitness Contest? Register here to get started on this journey to a happier, healthier you! After completing this form, please bring you payment of $10 to our office at 3005 Silver Creek Road Suite 214, San Jose, CA 95148 during the first weigh-in session.

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First and Last Name *
Date of Birth *
Phone Number *
Email Address *
Gender *
Were you referred to this contest by a friend? If so, please state their first and last name:
By checking this box, you agree to abide by the rules of the contest and agree to compete fairly. You are also aware that we want to encourage participants to lose weight in a healthy manner and that we are not health and fitness experts in any way. *
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