Request the Exercise and Nutrition Program

If you have used this program before and have received a re-order form in the mail, complete the following fields, and you local Modern Woodmen representative will donate it to you again.

You'll find your registration number on the upper right-hand corner of your re-order form.

*Enter your registration
number:

*First Name:

*Last Name:

*Ship To Address:
(Cannot ship to P.O. Boxes)

P.O. Box:

*City:

*State:

*ZIP Code:

*Email Address:

*Phone (Daytime):

Fax Number:

*Address above is:

School/Organization

Residence

*Name of School/ Organization using program:

*City:

*State:

*ZIP Code:

*Event Date:

Which level of materials do
you need?

Level 1 (Prekindergarten to 2nd Grade)...

Level 2 (3rd grade to 5th grade)...

Level 3 (6th grade to 8th grade)...

Level 1 - Number of Children

Level 1 - Number of
teacher's manuals needed

Level 2 - Number of Children

Level 2 - Number of
teacher's manuals needed

Level 3 - Number of Children

Level 3 - Number of
teacher's manuals needed

* Required Fields