LAST STEP!! Please Complete This Application
If this form isn't completed we won't be able to enroll you into the challenge.
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Which Program Are You Applying For?
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SHRINKYOUR BELLY CHALLENGE
NUTRITION + ACCOUNTABILITY COACHING
1:1 PREMIUM COACHING
Other
If you selected "Other" please specify?
What is your current occupation?
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What Is Your Goal? Please be specific. (E.g. lose 20lbs, Tone up, Drop Body Fat, Improve health etc)
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What have you tried in the past? (Select those which apply)
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Gym Membership
Personal Trainer
Shakes/Supplements/Pills Etc
At home Diets/Workout Plans
Other
What stopped you from achieving your goal AND/OR sustaining it?
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What would need to happen in one year for you to look back and think "This was the best decision I've ever made, I'm so grateful I did this."?
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On a 1 to 10 scale, how dissatisfied are you with your current state? 1=Comfortable 10=Will Do Whatever It Takes To Change.
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1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Is your spouse supportive of your health goals?
We work off a waiting list primarily. If selected, why will you be a good client to work with?
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Are you willing to invest financially to reach your goals?
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If Accepted, How soon are you willing to get started? NOTE: If you're not ready to start please wait and schedule when you are.
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Please Type the word "YES" if you agree with the above statement
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Please Type "Yes" To The Following Statements If You Agree
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Submit
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