Fields with asterisks (*) are required.

First name *

Last name *

Email *

Requested fitness equipment *

Approximate equipment cost? *

< $100.00

> $100.00

Other

If you selected other, please incude approximate cost.

Outline health benefit. *

Is there adequate room for the equipment? Please consider safety and space limitations. *

Supplemental information you would like to include to encourage purchase consideration (dimensions, website URLs, etc.)