Strong Willow Elder Membership Form
#Healthback Lets Go!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth (Celebrated or the date on Birth Certificate)
Gender
Female
Male
Prefer not to answer
Other
Do you have any medical conditions or injuries?
Yes
No
Please share details for any accomodations you may need:
Current weight
Current height
How many months would you like to participate in the Strong Willow Circle?
Please Select
1 Month
3 Months
6 Months
1 Year
How many hours per day do you have movement like walking or taking grandkids to park and active play?
Please Select
1 Hour
1-2 Hour
2-4 Hour
4-6 Hour
More than 6 hour
Please list the goals according to your priority. (First 3 option will be prioritized.)
Stress impacts each one of us different. Our levels of sensitivity are different depending on how we cope. Please share a little about yourself here:
Very Frequently
Sometimes
Rarely
Never
Praying
Traditional Meals
Being active
Spiritual Practice
Please share here about your community or family needs. (Optional)
If you want to add your current picture or any relevant documents, please upload here.
Browse Files
Drag and drop files here
Choose a file
Cancel
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If you have a walking or health routine right now, please share it.
Please share your motivation, obstacles, etc. for being in the group. Any concerns or unsafe people for you in community can be listed here. We are doing our best to ensure a brave and safe place so let us know what that looks like for you!
How motivated are you to change health habits in your life?
Not much
1
2
3
4
Very
5
1 is Not much, 5 is Very
START!
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