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EmpowerU Application Form
First Name *
Your answer
Last Name *
Your answer
Email *
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Phone Number *
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Gender *
Date of Birth *
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List any current and/or past injuries, surgeries and/or any other medical limitations. If none, write “none”. *
Your answer
What is your #1 struggle to improve your health, fitness, nutrition, strength, mindset and/or overall well-being? *
Your answer
What have you tried in the past that hasn’t worked? *
Your answer
What is/are your current goal(s) related to health, fitness, nutrition, strength, mindset and/or overall well-being? *
Your answer
What does success look like to you? What would you like to accomplish in the next 3 months? *
Your answer
Which best describes you? *
On a scale of 1-10 how committed are you to become EMPOWERED to take control and to find your inner XENA? *
Meh, I'm OK being Edna.
I WANT TO BE XENA!
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