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Fitness Application Form
Please fill the form carefully
1
Step 1
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Step 2
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Step 3
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Step 4
5
Step 5
*
Full Name:
*
First Name
*
Last Name
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Email id:
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Please enter valid email address
Mobile No:
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Invalid phone number.
The value must be less than or equal to 20
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Address:
Address Line1
Address Line2
Land Mark
City
State
Country
Please select country name
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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Zip Code
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Childrens Names & Ages:
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Next
Fitness Enrollment Information
*
Which Classes and events are you interested in:
4 Week Challenge
Child Friendly Classess
Boxing
Drumfit
Abs-Butts-Thighs
Bootcamp
Nutrition Workshops
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How did you hear about us:
Flyer
Referred by a friend
Personal Invitation
FaceBook
Meet Up
Instagram
Glam Adelaide
Adelaidy
Email
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Invited by (name of Health & Fit Coach):
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Next
Previous
Health & Lifestyle Questionaire
Do you feel you receive balanced nutrition from the foods that you eat:
No
Yes
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Would you like to improve your energy levels:
Yes
No
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How would you describe your energy levels:
Ok
Up & Down
Lethargic
Excellent
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Would you like to: (choose whats applicable for you):
Lose Weight
Reduce Body Fat
Gain Muscle
Maintain weight
Improve general wellbeing
Lose Baby Weight
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Do you exercise:
Not at all
Occasionally
Regularly
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If so, how do you like to move your body:
Walking
Running
Gym
Yoga
Pilates
Swim
Cycle
Dance
Team Sport
Barre
Golf
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Would you like to improve your sports performance/fitness/stamina:
Yes
No
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On a scale of 1-10 (1=Not at all) + (10=I want it yesterday) how motivated or serious are you about reaching your goals as this time:
WORST
BEST
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Next
Previous
Medical Information
Do you suffer from any health complaints? Eg. asthma, allergies, diabetes,blood pressure, cholesterol, arthritis, skin disorders (acne, rashers, psoriasis, eczema) chronic fatigue, other:
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*
Please review the following check list:
YES
NO
Do you smoke
Drink Coffee or Coffee Drinks
Drink energy drinks
Drink soft drinks
Do you eat breakfast
Do you get at least 6-8hrs sleep
Do you drink at least 2L water
Do you eat take away food
Do you eat fast food
Crave sugar
Crave salt
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*
Type a question:
YES
NO
Back pain
Reflux
Depression
Anxiety
Bloating
Digestive Issues ie IBS
Indigestion
Water retention
PMS/Mood Swings
Pregnant
Breast Feeding
Menopause
Diabetes
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*
Any other health conditions or past injuries:
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Do you have any particular health goals in mind and any particular Special event/Wedding/Holiday:
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Previous
Disclaimer
Fitness Liability Release Waiver
By checking this field and submitting this form.
By checking this field and submitting this form.
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Submit