KwintonLS Fitness
Application for personalized coaching plans
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Best Means of Communication
*
Call
Text
Email
Instagram (DM)
Instagram handle?
What is your current occupation?
What results are you looking to achieve?
*
Lose Body Fat
Get Lean & Toned
Improve Energy Levels
Increase Lean Muscle
Other
If you want to lose body fat, how much do you want to lose?
under 10lbs
10-20lbs
20-30lbs
30-50lbs
Over 50lbs
If you want to build muscle mass how much? (lbs.)
5 lbs.
10-15 lbs.
15-20 lbs.
How often do you consume alcohol
*
Daily
3-5 times week
On weekends
Few times a year
Current stress levels
*
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Current height and weight?
*
What sort of things have prevented you from achieving your goals in the past?
*
Do you have a gym membership or access to gym equipment, if "No" would you consider paying for a gym membership?
*
What does your current diet look like? (please include drinks as well, soda, coffee ect)
*
Any recent injuries or physical limitations?
*
How much are you willing to invest in your personal development program?
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please verify that you are human
*
APPLY NOW
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