Summer Shred 21 Day Wellness Challenge Registration
July 10-July 30
Your Name
First Name
Middle Name
Last Name
Gender
Please Select
Male
Female
N/A
E-mail
example@example.com
Mobile Number
Who is your Herbalife Coach? (Who are you registering under)
What are your wellness goals?
I want to lose weight
I want to tone up (lose body fat)
I want to gain energy
I want to sleep better
I want to feel more confident
I want to gain weight/muscle
Other
If you want to lose weight, how much weight would you like to lose overall?
Less than 5 pounds
5-10 pounds
10-15 pounds
15-20 pounds
20+ pounds
Do you exercise? On a scale of 1-5 (1 being never and 5 being regularly), how often do you exercise?
How much water do you drink in a day?
What other drinks do you drink in a day, and how much?
Do you feel that you receive balanced nutrition from the foods you eat?
Do you eat 3 meals per day? If not, which meal do you normally skip?
On a scale of 1-5 (1 being terrible and 5 being amazing), how would you describe your energy level?
On a scale of 1-5 (1 being terrible and 5 being amazing), how would you describe your sleep?
Do you have any health concerns?
Diabetes
Heart Disease
Stroke
Obesity
None
Other
The wellness challenge will be providing a lot of value. It is $20 per person and you are provided one on one coaching, meal guides, recipes, workout plans, and a team of coaches who are here to guide you towards your results. How will you be paying today?
Cashapp ($hayleygrizzle)
Venmo (chase-riker)
PayPal (hayley.n.grizzle@gmail.com)
Apple Pay (910-540-4881)
Submit
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