Fitness Enrollment Fitness Program Enrollment Form Fields marked with an * are required First Name Last Name Date Divider Enrollment Type: * First Time Enrollment (Effective Immediately) Open Enrollment Change If you are changing enrollment please specify: May 1st November 1st Divider Program to be enrolled in (select one) * Gym Reimbursement Physical Wellness Related membership or equipment Pro-Health & Fitness Gym Corporate Membership (disclosure: East Coast will pay for the staff membership, any additional family members membership payments will be deducted from the employees paycheck) HTML Open Enrollment periods are April 1 - 30 OR October 1-31 If you are a human seeing this field, please leave it empty.
