HerHealthyLife Application
Name
*
First Name
Last Name
Phone
*
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you service-connected?
*
Discharge Type
*
Entry Date
*
-
Month
-
Day
Year
Date
Are You a Combat Vet?
*
Yes
No
Discharge Date
*
-
Month
-
Day
Year
Date
Branch of Service?
*
What Component
*
ex: National Guard, Reserve, Active Duty, etc.
Please Acknowledge
*
(You will be required to produce proof of military Service such as a DD214 or other official documentation)
Height
*
Age
*
Weight
*
To your knowledge, do you have any heart, respiratory, or any other medical issues that could affect your ability to exercise?
*
Yes
No
This is a 6-month program. Will you commit to at least 3-4 times a week to complete tasks required by the program?
*
Yes
No
Do you have a Fitbit or something similar to track your steps and heartrate?
*
Yes
No
Most of your work will be online. Occasionally, you will be required to meet up in person with facilitator. Are you will to do that?
*
Yes
No
List 3 things you expect to happen as a result of you participating in this program:
*
Please verify that you are human
*
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