Thank you for showing interest in a Healthways product, we would like to know more about your location. Please remember that as you submit this form it is for the sole purpose of submitting information for future reference. This provided information will be stored in our database and Healthways will contact you if there is a need for more information.

If you are an eligible member who has access to a Healthways benefit, please ask the fitness center that you are interested in using to complete this form.

Location Name *
Contact First Name *
Contact Last Name *
Title within Fitness Center *
Email *
Address *
City *
State/Province *	Please Select... Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland and Labrador New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip *
Website
Phone *
Fax
Category that best describes your center *	--None-- Coed Women's Men's
Healthways Product Interest *	SilverSneakers Forever Fit PRIME Affinity
Monthly Dues for a Standard Membership
Monthly Dues for a Senior Membership

* indicates a required field.