Elevate 365

EVEVATE 365

Program Application
Full name

First NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Contact Phone Number

Area CodePhone Number
Emergency contact

First NameLast Name
Relationship
Phone number

Area CodePhone Number
Why would you like to participate in the Elevate 365 Program?
What is your experience level in the gym on a scale of 1-10?
Please list any dietary restrictions.
What size t-shirt would you like?
What would you like to accomplish throughout this program?
Please read the questions carefully and answer each one honestly: check YES or NO.

Rows	Yes	No
Would childcare be a barrier to attend the program?
Do you have history of Substance Use Disorder?
Have you ever struggled with body image?
Are you available to attend the program 2 days a week?
Do you have interest in yoga & meditation?

EVEVATE 365