Online Programming Intake Form

Online Programming Intake Form
Full Name*

First NameLast Name
Email*
Phone Number*
What are your goals for online programming (select all that apply)*

Athletic performanceImproved overall healthInjury rehabImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Are you training for a specific sport/event?*
Any other details you want to share about your training goals?*
How often do you currently train?*
How frequently can you commit to training? This will tell me how many days I will need to program for you?*

1-3 times a week3+ times a weekOther
What are your expectations of me as your coach?
Are you interested in a gym membership? *Includes remote access to our facility 24 hours a day, 365 days per year

YesNoInterested! Please send me more information (Pricing, terms of membership, etc.)
Medical and Health Information
Please list any health issues (or medications) that could impact our training together.
Please list any injuries that could impact our training together, and if any additional therapies are being undertaken to address the injury.
Please Read The Following Terms and Conditions
1.) CANCELLATIONS

Cancellations to our contract should be made at least 7 days in advance of your next billing cycle. Contracts cancelled less than 7 days in advance will be charged in full to the client.

2.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS

YesNo
Thank you for your interest! We will review your intake form and get back to you within 48 hours.
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Online Programming Intake Form

Medical and Health Information

Please Read The Following Terms and Conditions