Before we get into the nitty gritty, let's cover some basics!
What county do you currently live in?
*
Pasco
Pinellas
Hillsborough
Other in FL
Other outside of FL
So you're interested in being a part of our 2022 wellness program? Awesome
Let's get some contact information.
What's your first and last name?
*
First Name
Middle Name
Last Name
Suffix
DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What's your instagram handle?
Example (Society66)
What's your facebook handle?
Example (Society66)
E-mail :
*
Where the confirmation will be send to
Okay, now let's get to know you better!
Why do you want to be part of this program?
*
0/500
Tell us a little about you, your current level of wellness, and where you would like to improve
*
0/500
The areas that we will be working on are mental wellness, exercise, nutrition, sleep, and community. What would those things mean to you and how ready are you to work on them each day?
*
0/500
What wellness endeavors have you gone on in the past and how long did you stick with them?
*
0/500
What might get in your way of working on this journey?
*
Select the option that best matches your commitment level to a year long program.
*
I'll give it my best shot!
I'm 100% in!
I'll try it out!
I may stumble, but I won't give up!
I want to live a life of purpose. I have big dreams and I'm ready to work hard to make them a reality!
Do you understand that if accepted you will be required to attend one group session a month (with more offered), check in at least twice a week, and share your progress?
*
Yes
No
On a scale of 1-5, how willing are you to share your journey socially?
*
1
2
3
4
5
Now, let's figure out if you qualify!
We are almost done! (these answers will not be shared unless you are accepted)
Has your doctor okayed you for a wellness routine?
*
Do you identify as having a mental health condition?
*
Submit
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