BLKFORM Intake

Client Info
BLKFORM Dallas: Private Founder’s Intake. We are currently selecting 5 individuals for our July 2026 Soft Launch. This is a high-performance, 1-on-1 environment centered on Kinesiology-based longevity.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Health & Medical History
Do you have any current injuries or medical conditions?
Are you currently on any medication?
YesNo
Fitness & Training Goals
What are your top 3 fitness goals?
What are your biggest challenges?
YesNo
2x/week3x/week4x/week5x/week
Rate your fitness level
Nutrition & Lifestyle
Describe your typical daily meals
How many hours of sleep do you average per night?
YesNo
YesNo
Motivation & Mindset
Why did you choose to work with a trainer?
What has held you back in the past?
Liability Waiver
I understand that participation in fitness training involves risks of injury… I voluntarily accept all responsibility and release BLKFORM Brand and its affiliates from liability.
Media Release
I grant permission for BLKFORM Brand to use photos or videos from my sessions for marketing or promotional purposes.
Checkbox Consent
Are you prepared to invest in a $1,200/month private coaching environment?
What is your primary goal for building a physical legacy?
YesNo
Which Legacy Tier are you most interested in?
Signature
Signature