Welcome & Enrollement Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
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Austria
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The Bahamas
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Belgium
Belize
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
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Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Cote d'Ivoire
Croatia
Cuba
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El Salvador
Equatorial Guinea
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Ethiopia
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Fiji
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French Polynesia
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The Gambia
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Greece
Greenland
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Guadeloupe
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Guinea
Guinea-Bissau
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
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Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
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Fitness Enrollment Information
Which Classes and events are you interested in?
*
Small Group Fitness Training
Semi-Training with a friend
1:1 Personal Training
Live Group Virtual Training
Live 1:1 Virtual Training
Mom and Teen in Motion
Starter Wellness Program
How did you hear about us?
*
Flyer
Referred by a friend
Personal Invitation
FaceBook
Meet Up
Instagram
Glam Adelaide
Adelaidy
Email
Other
Invited by
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Health & Lifestyle Questionaire
Do you feel you receive balanced nutrition from the foods that you eat?
*
No
Yes
How would you describe your energy levels?
*
Ok
Up & Down
Lethargic
Excellent
Would you like to improve your energy levels?
*
Yes
No
Would you like to: (choose whats applicable for you)
*
Lose Weight
Reduce Body Fat
Gain Muscle
Maintain weight
Improve general wellbeing
Lose Baby Weight
How much would you need to gain/lose to reach your ideal weight?
*
Do you exercise
*
Not at all
Occasionally
Regularly
If so, how do you like to move your body?
Please Select
Walking
Running
Gym
Yoga
Pilates
Swim
Cycle
Dance
Team Sport
Barre
Golf
Other
Would you like to improve your sports performance/fitness/stamina?
*
Yes
No
On a scale of 1-10 (1=Not at all) + (10=I want it yesterday) how motivated or serious are you about reaching your goals as this time?
*
1
2
3
4
5
6
7
8
9
10
WORST
BEST
1 is WORST, 10 is BEST
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Medical Information
Do you suffer from any health complaints? Eg. asthma, allergies, diabetes,blood pressure, cholesterol, arthritis, skin disorders (acne, rashers, psoriasis, eczema) chronic fatigue, other?
Please provide and explain.
Please review the following check list
*
Rows
YES
NO
Do you smoke?
Drink Coffee or Coffee Drinks?
Drink energy drinks
Drink soft drinks
Do you eat breakfast?
Do you get at least 6-8hrs sleep
Do you drink at least 2L water
Do you eat take away food?
Do you eat fast food?
Crave sugar
Crave salt
Type a question
*
Rows
YES
NO
Back pain
Reflux
Depression
Anxiety
Bloating
Digestive Issues ie IBS
Indigestion
Water retention
PMS/Mood Swings
Pregnant
Breast Feeding
Menopause
Diabetes
Any other health conditions or past injuries?
Do you have any particular health goals in mind and any particular Special event/Wedding/Holiday?
*
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Disclaimer
FITNESS LIABILITY RELEASE WAIVER
Submit
Should be Empty: