New Member Registration

1
First Name* This field is required.
2
Last Name* This field is required.
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Area Code
Phone Number
5
Street Address* This field is required.
6
Address Line 2
7
City* This field is required.
8
State* This field is required.
9
Zip Code* This field is required.
10
Date of birth* This field is required.
Date
Month
Day
Year
11
If you're on Instagram, what is your username?
12
How did you hear about us?* This field is required.
13
Emergency Contact Name* This field is required.
First Name
Last Name
14
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
15
Emergency Contact Relationship to You* This field is required.
16
Your Primary Care ProviderFor example, Doctor's name and phone number. If none, leave blank.
17
Do you have any medical conditions, allergies, and known food sensitivities?* This field is required.
YESNO
18
List any medical conditions, allergies, and known food sensitivities.
19
Do you have a history of disordered eating?* This field is required.
YESNO
20
Please explain.
Huge
Large
Normal
Small
Ok
Ok
21
If you have completed a Whole30 previously, what was your experience? * This field is required.
22
What is your 'why' for this Whole30?* This field is required.
23
Best Day & Time for Weekly CallsCurrently weekly calls are scheduled for Sundays at 6:30 PM CT. If there is a better time that universally works for everyone we'd be open to changing it. Please include some day and times that would work on a reoccurring basis.
24
How can we support you best? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
25
What are some topics you'd like us to cover in our weekly calls?* This field is required.
26
What are your expectations of us?* This field is required.
27
Tell us a fun fact about you!* This field is required.
28
Finalize Registration* This field is required.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Imperfectly Phil'd Membership
$199.00+
Back
Enter Coupon
Total cost $0.00
Finalize Registration
loading smart payment buttons...
The payment is ready! It will be completed once you submit the form.
Should be Empty: