Wellness Community for Women by Deju- Intake form

INTAKE FORM

Wellness Community For Women (Virtual group fitness and nutrition coaching) - Read more coaching information at the bottom
First and Last Name*
Phone Number*
Email address*
example@example.com
Do you have any medical condition that could hinder your fitness and nutrition lifestyle changes?*
Type YES or NO
If yes, we encourage you to consult with your healthcare provider before starting any health modifying journey
Have you had a bloodwork completed within the last 6 months*
Type YES or NO
Have you tried any diet in the past or are you currently using one?*
Type YES or NO then specify
Have you practiced intermittent fasting before and for how many hours?*
Type YES or NO then specify
Do you smoke?*
Type YES or NO
Do you consume alcohol?*
Type YES or NO
Do you have any allergies?
Please state your ideal Breakfast, Lunch, and Supper/dinner*
Multiple answers are welcome
What is/are your staple food?*
(Foods that you cannot do without daily) Multiple answers are welcome
What are your goals for joining the wellness community for women's fitness and nutrition group coaching? E.g., weight loss, build muscle, make healthy choices, be accountable to someone, etc. Please be specific*
Please be specific
What are the challenges that could hinder you from attaining your goals? E.g., time, cost of food, family, work schedule, cravings, existing lifestyle, hate cooking, etc.*
Please be specific
Would you like to be paired with a group member (Accountability partner)? This is optional*
(Optional) Type YES or NO
At my risk, I consent to participate in the Wellness Community for Women group coaching by Engage Wellness (EW). The coach and Engage Wellness will not be responsible for any injuries incurred before, during, or after my membership. I will ensure safety in my space during personal or group fitness.

I consent to be respectful in the community and keep all other member's information confidential. Also, EW can share my anonymous or named testimonials with their clients.
Sign your FULL NAME here to give consent*
Please be specific
Date*

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Date
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Thank you for filling out the form! You have made a valuable decision for yourself today. I am Deju, and I will be your coach.

This is a virtual group coaching (Orientation and invitation into the WHATSAPP GROUP will be done 5 days before coaching commences officially and you will be removed from the WhatsApp group after post-coaching evaluations).

Once the form is completed and your application is approved, all subscription payments are payable via cheque addressed to Engage Wellness, e-transfer to info@engagebydeju.com (If applicable) Once payment is received, you will be added to the WhatsApp group when due.

$100 fee for November 2025 cohort.

What to expect as a member of our community

NOVEMBER 30-DAY WELL CHALLENGE - An itinerary will be sent to your email.

- This comprehensive coaching program details mindset reset kitchen reset, weekly fitness plan, nutrition ideas, detox/bowel movement principles, intermittent fasting plan, motivations, gratitude/self-care, etc. Please we expect full participation.

- A guided fitness and nutrition challenges, self paced

- A one-week water challenge + other weekly challenges

- Kitchen reset (The instructions will be given when admitted into the group)

- Weekly 15-30-minute virtual or recorded fitness sessions

- Bowel care techniques

- Intermittent fasting and how to break a fast

- Weekly check-in

- Open conversation

- ASK THE COACH

- Know thyself

- A paired accountability partner (Optional)

- ONE 30-Minutes wellness consultation with coach Deju (only valid during the coaching period - know your body type and receive customized recommendations for your macronutrient ratio)

- Other details to be communicated

THANK YOU, AGAIN, FOR TAKING YOUR HEALTH JOURNEY SERIOUSLY! LET'S WIN TOGETHER, WELL WOMAN. YOU ARE WORTHY OF A WELL LIFE.

** terms and condition apply to acceptance into the community

YOU BELONG!
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INTAKE FORM