Clone of 6 Week Weight Loss Challenge Application Form

1
Name* This field is required.How do we address you?
First Name
Last Name
2
Birth Date* This field is required.Tell us your birth date.
Month
Day
Year
3
Phone Number* This field is required.
Area Code
Phone Number
4
E-mail* This field is required.
example@example.com
5
How did you hear about us?* This field is required.
Friend
Current Client
Social Media
Advertisement
Google Search
Website
6
Current weight* This field is required.In kilograms (E.g. 95.0)
7
Current height* This field is required.In meters (E.g. 1.80)
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I would like to lose....?* This field is required.Please note this is your LONG TERM goal not what you want to lose in the next 6 weeks
1-7 KGs
8-14 KGs
15-21 KGs
22-28 KGs
29+ KGs
9
Are you able to commit to our 3x a week exercise program?* This field is required.Recordings available if you miss some Live sessions.
Yes
No
10
Are you able to prepare at least 2 meals a day?* This field is required.A customized meal plan and easy recipes will be given to you.
Yes
No
11
Have you had
Heart Attack
Heart Surgery
Cardiac Catherisation
Coronary Angioplasty
Pace maker
Heart Valve Disease
Heart Transplant
Heart Failure
Congenital Heart Disease
Take heart medication
Diabetes
You have asthma or lung disease
None of the above
12
Do you experience any of these symptoms?
Chest discomfort with exertion
Unreasonable breathlessness
Dizziness, fainting or blackouts
None of the above
13
Do you have any health factors we should know?
You have had a hysterectomy or are post menopausal
You smoke, or recently just quit smoking.
Your blood pressure is above 140/90 mm hg
You take blood pressure medication
Your blood cholesterol level is above 6.2 mmol/L
You are more than 45 kilos overweight
Your fasted blood sugar levels is above 5.5 mmol/L
None of the above
14
Do you have musculoskeletal problems that limit you from exercising?E.g. Knee pain, back pain, shoulder issues
Yes
No
15
If yes to musculoskeletal problems please list them here
16
You take prescription medication? Please list them here
17
Other illnesses/conditions you think we should know about? Please list them here
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Declaration

The health and medical information provided is true and accurate and to the best of my knowledge. Whilst I realise that I will be provided with an exercise and weight loss program that is safe and effective, I am choosing to participate at my own risk.

I declare that I am not pregnant and do not plan on becoming pregnant during the course of the challenge. If my health, or any other condition changes that would impact any of the above questions, I will advise my trainer and have this updated immediately.

By signing this form, I agree to release all forms of liability and waiving any rights of mine or that of my successors to bring legal action or assert a claim against KD Trainer or that of their employees, agents or contractors.

Disclaimer

The information provided to me during the 6 week challenge will be useful information on weight loss, healthy eating and exercise and is not intended as a substitute for advice from a medical practitioner or health care provider. Before starting any weight loss program or exercise you should gain advice or guidance on any health conditions/illnesses. I understand that everyone will lose weight at different rates and so I may lose weight slower or faster than others I have seen.

Other Terms

I understand that all information provided to me will be kept confidential and not shared with others.

Upon signing this application I understand that I am liable for all the costs associated with this challenge, and that no refunds will be available except for three conditions:

1. Doctors letter was received advising that you were unable to continue due to a medical condition

2. No weight loss achieved at the end of the program after complying to all our training and recommendations

3. Failure to attend 80% of the sessions provided by our team

at which point I would be entitled to a pro-rated refund of your remaining program.

I have read the above statements and agree to follow the program exactly as outlined by my trainers and dietitians. I have read this application form in its entirety including the declaration, disclaimer and other terms sections and understand the information that has been provided to me.
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SignaturePlease sign your waiver to complete the enrolment.
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