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Way to Wellness Online Registration

Way to Wellness Online Registration

* Indicates required information
2015 Session (Choose 1) * 

Last Name * 
First Name * 
Date of Birth  *  (mm/dd/yyyy)
Age * 
Address * 
City * 
State * 
Zip * 
Phone Number * 
Work Number (if applicable) 
Relationship to St. Mary Medical Center * 

E-mail Address 
Emergency Contact Name and Phone Number 
Have you taken Way to Wellness before? 
Is your medical insurance through St. Mary Medical Center * 
Medical Insurance Carrier * 
(For Colleagues Only) Shift: 

Are you currently a member of the St. Mary Gym? 
Authentication * 

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