Derek Bolt Coaching Application

Derek Bolt Coaching Application

Ready to build the body and confidence you've been working toward? Fill this out and I'll review it personally. Be honest: the more real you are, the better I can help.
Full Name*

First NameLast Name
Email Address*
example@example.com
Social Media Handle
Location*

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age*
Height (Feet and Inches)*
Current Weight (Lbs)*
How would you describe your current fitness level?*
How much experience do you have with bodybuilding?*
What are your primary long term fitness goals? (e.g. muscle gain, fat loss, strength, endurance). *
What are your primary short term fitness goals? (e.g. cut down for summer, get bigger, bench a certain weight).
Do you have any current or past injuries or medical conditions we should be aware of? Please give details.
Briefly describe your current fitness routine and experience. For example: How many times a week do you work out? What is your split? What level of intensity do you lift at - how close to failure are you generally? How much cardio do you do per week? What is your heart rate when you do cardio?*
Describe your current diet. Do you count your calories? What are you macros if so? What foods is your diet typically comprised of?*
Why now? What's made you decide to pursue coaching at this point in your life? There's no wrong answer. I just want to understand where you're coming from.
Please upload recent picture of yourself.

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On a scale of 1–5, how ready are you to fully commit to this right now? (1 = just exploring, 5 = ready to start immediately)Whatever your number, be honest. This helps me understand where you are so I can meet you there.

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5

1 is Worst, 5 is Best
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