New Client Registration Form

Full Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

E-mail *

example@example.com

How did you hear about us? *

Gender:

Male Female

Date of Birth: *

Date

Preferred way of contact: *

Email Text Phone call

Have you been diagnosed with diabetes? *

Yes No

Have you been diagnosed with pre-diabetes? *

Yes No

Have you been diagnosed with hypertension? *

Yes No

Are you physically active? *

Yes No

Have you ever been told you have high blood sugar or high A1C?

Yes No

Do you have any medical conditions we should know about?

Yes No

Pre-Diabetes Risk Test

Do you have a mother, father, sister, or brother with diabetes?

Yes No

What is your weight status? (Based on the chart below) *

Lower than column 1 Column 1 Column 2 Column 3

Age Range *

Less than 40 40-49 50-59 60 and older

Have you ever been diagnosed with gestational diabetes?

Yes No

Are you Hispanic or Latino? *

Yes No

What is your race?

American Indian or Native Alaskan Asian or Asian America Native Hawaiian or other Pacific Islander White Other Prefer not to report

What is the highest level of education you have achieved?

Less than 12 (no high school diploma or GED) High school diploma or GED Some college or technical school 4 year college graduate or higher Prefer not to report

Eligibility Requirements

You must be at least 18 years or older (if under 18, parent must participate with you).

Employment Information

Are you employed? *

Yes No

Name of Employer *

If you are retired, homemaker, unemployed or self-employed, please enter that information.

PLEASE READ THE FOLLOWING DISCLAIMER

1. I acknowledge that all the information provided on this application is true and accurate and any false or misleading information submitted herein is grounds for my immediate elimination from consideration. This application and any other material submitted by me, including pictures, becomes property of B2H&W and Associates, and shall not be returned whether or not I am selected as a participant. I also hereby understand that even if I meet the eligibility requirements, B2H&W and Associates has no obligation to interview me, and/or select me as a participant. I further understand that by submitting this application it no way guarantees selection, as it is merely for the purpose of evaluating potential participants.

2. I, for myself, my heirs and assigns, do hereby waive, release, and forever discharge B2H&W and Associates, their officers, agents, employers, representatives, investors and executors from injuries or damages resulting from my participation in their program. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability, now or in the future, for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf, or in any way arising out of or connected with my participation in any activities of B2H&W and Associates.

3. I understand and am aware that strength, flexibility, and aerobic exercise are a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death and that I am voluntarily participating in these activities. I hereby agree to expressly assume and accept all risks of injury or death associated with any program of B2H&W and Associates.

4. I understand that any photographs taken during these classes may be used on promotional materials, printed or electronic.

By signing below, you acknowledge that you have read the disclaimer above and agree with its entire contents and that all the information provided on this application is true and accurate, and any false or misleading information submitted is grounds for my immediate elimination from consideration.

Signature *

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26-Week Online Program

26 Week Online Program Bridge 2 Health and Wellness 26 Week Online Program teaching how to live a healthy lifestyle that helps you loss weight, improve attitude and decrease the need for medications.

$ 50.00

Enter coupon

Total

$ 0.00

Location of Blood Assurance Donation Site. *

Payment Methods

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First Name	Last Name
Credit Card Number	Security Code
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Please click one of the PayPal options to complete payment and submit the form.

Client Details

Demographic Information: