Start Form

Staying Alive in 2005 Official Start Form

Take this form with you when you get weighed in at the Mall of America, Gold's Gym, or by a physician or a nurse. Fill in all the fields. Keep this form until you get further direction from the show or on drphil.com. This is your OFFICIAL entry form, and you will need it in order to bump someone out of the Challenge.

Challenger's Name: ___________________________________________________

Date: _________________________

Height: ____________

Weight: ____________

Percentage of Body Fat or BMI Index (if available): ____________

Goal Weight: ____________



Official's Signature and Printed Name: ____________________________________

Official's Title: ______________________________________________________

Phone Number: _________________________________