3:23 Training & Development

3:23 Training & Development

Skills & Goals Evaluation
Athlete Name

First NameLast Name
Parent/Gaurdian Name

First NameLast Name
Preferred Cell
Format: (000) 000-0000.
Preferred Email
example@example.com
Preferred Method of Contact (Call, Text, Email)
example@example.com
Athlete Birth Date

MonthDayYear
Date
Athlete's Grade Level
Athlete's School Name
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Please provide contact information of your athlete's wrestling coach if possible.
Please state if you have current/previous health diseases/issues.
Please state whether you take any medication.

Health & Wrestling Goals

Rows	Yes	No
Have you had any injuries or surgeries in the past 12 months?
Do you have any health related issues that would potentially impede your ability to compete this year?
Are you using any additional vitamins or supplements?
Are you looking to either drop or go up a weight class compared to what you are currently weighing?
Have you worked with a private wrestling coach before?

How many years have you been wrestling?

0

1

2

3

4

5

0 is , 5 is or More
How would you rate your daily nutrition?

0

1

2

3

4

5

0 is Poor, 5 is Excellent
What are your wrestling goals this year?

Win my first matchWin a region titleWin a state titleMake varsityQualify for the state tournamentAll-AmericanOther
What are your academic goals this year?

Get above a 3.0 GPAPay attention in class moreDevelop better study habitsMake all A'sOther
Any additional information that you would like to share/elaborate on regarding your wrestling or academic goals?
Do you have any other goals outside of wrestling and school that would be helpful for me to know?
Do you have a personal development or positive mindset routine established? If so, please describe below (i.e. - books you read, podcasts you listen to, etc.)
Please select the best times you can meet.

Early Mornings (M-F before school)Mornings (Weekends)It depends on my schedule - can we be flexible?
Do you plan on having a training partner or will you need to train one-on-one with Caleb? (**Note: private lessons are limited to athletes local to Nashville with select availability for athletes in North GA.)

I'll have a partnerCalebOther (not interested in one-on-one lessons, etc.)
What area are you most wanting to improve in?

Neutral (Takedowns, defense, scrambling, etc.)Top (Turns, breakdowns, etc.)Bottom (Escapes, reversals, etc.)Habit DevelopmentNutritionAll of the aboveOther
What days & times would be best for a free consultation call?

Weekdays in the morningWeekdays after work (early evening)Weekdays after work (late evening)Weekends (Morning)Weekends (Afternoon)Other
Release and Acknowledgement
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.

3:23 Training & Development has informed me that I am the only responsible party both for all the injuries during the training program and incorrect information. I release and discharge 3:23 Training & Development and its coaches, administration and workers from any disclosure of my personal information in this Intake Form.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the 3:23 Training & Development staff immediately.
Date

MonthDayYear
Date
Client Signature
Should be Empty:

3:23 Training & Development

Release and Acknowledgement