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Fill in this Information to let us learn a little bit more about you. We will then contact you and set up a consultation

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Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
How Did You Hear About Ladies Fitcamp?*

Desired Start Date*
Date Format: MM slash DD slash YYYY
Desired Class Time*
- 5:30am
- 6:30am
What frustrations do you experience while trying to lose wieght?*
What is the biggest obstacle you have faced when trying to get in shape?*
What goals are you looking to achieve in your fitness?*
Medical History
Date of Your Last Physical*
Date Format: MM slash DD slash YYYY
Are you wearing an internal regulating device such as a pacemaker,or are you pregnant?*
- Yes
- No
Has Your Doctor Advised That You Excercise More?*
- Yes
- No
Are You Currently Receiving Physical Therapy?*
- Yes
- No
Are You On A Medically Mandated Diet Prescribed by Your Doctor or Registered Dietition*
- Yes
- No
Are you currently taking any Doctor prescribed medications?*
Have You sustained any injuries that may require excercise modifications?*
Emergency Contact Information
Name*
First Last
Relationship*
Phone*

Medical History