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EmpowerU Application Form
EmpowerU: focuses on supporting three pillars to enhance hormone balance; strength training to aid building lean body mass while decreasing fat, balanced nutrition and guidance with lifestyle coaching.
Email address *
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Instagram Handle (or FB Profile Name) *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Height *
Your answer
Weight *
Your answer
List any current and/or past injuries, surgeries and/or any other medical limitations. If none, write “none”. *
Your answer
Have you ever had hormone testing? If yes; please provide details and results and the healthcare provider you are seeing? *
Your answer
What is your #1 struggle to improve your 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 the best man you can be? *
I am tired and fatigued and OK with this
I want my best life and want to THRIVE!
A copy of your responses will be emailed to the address you provided.
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