THE BELOW INFORMATION NEEDS TO BE FILLED OUT IN ORDER TO PLACE YOUR NAME IN THE FILM AND TO HAVE YOUR COACH CONTACT YOU SO THAT YOU CAN START LIVING YOUR DREAM ! (Your email will be used for that purpose only.)


Full Name:
City:
State:
Email:

How would you like your Name/Business to be written in the movie:





Total Contribution:




"My Wish" is to:


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