Name
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First Name
Last Name
Email Address
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Phone
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Can you tell me a bit about what you have tried in the past in regards to health and fitness that has worked for you?
What things have NOT worked for you in the past?
This can include anything from diets to training programs, to past coaches and trainers.
Do you believe accountability has been an issue for you in the past?
Yes
No
Maybe
Do you have any specific health, nutrition and/or fitness goals in mind?
Do you have any time frame or significant event you are working towards as a goal date?
Do you have significant limitations and/or injuries that would prevent you from participating in workouts?
Please describe in detail.
Upon reaching your health, nutrition & fitness goals within our program, what would you envision as the ‘ideal’ result for you? Can you describe your ‘new’ self?
Tell me a little about your support system at home? Are the other members of your family on board with your mission?
Who does the shopping/cooking/meal planning at home?
Me
My spouse
I rarely cook at home
Other
What are your top health concerns at this time?
What do you expect from me as your coach?
I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any health and fitness program may be injurious to my health, am voluntarily participating in physical activity and Health Coaching with Sally Mae Fitness, LLC. Having such knowledge, I hereby release Sally Mae Fitness, LLC, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected there with and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments, which may affect my ability to participate in said fitness program. Please type your full name below to confirm you have read and understand the above statement.
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I, the undersigned, understand that the role of the Health Coach and Personal Trainer is not to prescribe or assess micro and macronutrient levels; provide health care, medical or nutrition therapy services; or to diagnose, treat or cure any disease, condition or other physical or mental ailment of the human body. Rather, the Coach is a mentor and guide who has been trained in holistic health coaching and Personal Training to help clients reach their own health and fitness goals by helping clients devise and implement positive, sustainable lifestyle changes. The Client understands that the Coach is not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional, and that any advice given by the Coach is not meant to take the place of advice by these professionals. If the Client is under the care of a health care professional or currently uses prescription medications, the Client should discuss any dietary changes or potential dietary supplements use with his or her doctor, and should not discontinue any prescription medications without first consulting his or her doctor. The Client has chosen to work with the Coach and understands that the information received should not be seen as medical or nursing advice and is not meant to take the place of seeing licensed health professionals. Please type your full name below to confirm you have read and understand the above statement.
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I, the, the undersigned, acknowledge that the I take full responsibility for my life and well being, as well as the lives and well being of the my family and all decisions made during and after this program. I expressly assume the risks of the Program, including the risks of trying new foods or supplements, and the risks inherent in making lifestyle and fitness changes. I release the Coach from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which I ever had, now have or will have in the future against the Coach, arising from the my past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Coach. Please type your full name below to confirm you have read and understand the above statement.
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I, the Coach, will keep the Client's information private, and will not share the Client’s information to any third party unless compelled to by law.
Congratulations on taking this very important step towards becoming your healthiest self! Please select your payment preference below to get started and receive your very own Welcome Package, delivered right to your inbox!
If at any time you need to cancel, just send me a quick email and I will take care of it! And if you want to return later, fantastic! You can re-enroll at any time!
*NOTE: The “Early Bird” Rate only applies to those who enrolled during the promotional period.
