The Reform Club Application Form
Please complete ALL questions - it will take approximately 5 mins.
Full Name
First Name
Last Name
Age
years
Current Weight
KG
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 00000000000.
Address (this is for supplement packages to be sent depending on which program you choose!)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What are your motivational reasons for wanting to join the Reform Club? Be specific.
Physical reasons for wanting to join the Couch to 5K program?
Cardiovascular improvements
Weight management
Strength improvements
Reduce feelings of discomfort/pain
Overall health improvements
Other
Current physical activity levels?
Current not training
1 session a week
2 sessions a week
3+ sessions a week
Program length preference?
4 weeks
8 weeks (FREE supplement package with this option)
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Do you have any diagnosed health conditions? Please list.
Do you currently take or have recently taken any medication?
Do you have any injuries?
Has anyone in your immediate family developed heart disease before the age of 60?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
Are you a current cigarette smoker?
Yes
No
No, but currently vape
No, but recently quit within 6 months
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Do you understand that consistent consumption of alcohol and junk food as well as non-adherence of planned sessions will result in the potential removal from the Reform Club?
Yes
No
The Reform Club requires full commitment with the minimum commitment starting from £49. Can you commit to these costs?
Yes
No
The Reform Club requires full commitment, running for at least 4 weeks. Can you commit to this duration as a minimum?
Yes
No
The Reform Club is not like a generic PDF you may have seen online. All sessions will be accessed through my app and are completely adaptable. You will also be required to complete home based strength, recovery stretches and mobility sessions as well as upload progress photos and record weight and times. Can you commit to this?
Yes
No
I offer a 25% discount when you sign up with a friend or family member? Is this something you'd like to consider?
Yes
No
What are your expectations of me as your coach?
What is the best time for me to call you to discuss moving forward?
Hour Minutes
AM
PM
AM/PM Option
Please sign to confirm you are happy to proceed
Continue
Continue
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