Program Launch Date: 5.14.21
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Email *
Full Name *
Phone Number *
Email Address *
How did you hear about our program? *
Why are you enrolling in our program?  What is your main goal? *
How many meals/snacks do you currently consume on average per day? *
How often do you do cardiovascular exercise per week? What is the duration? *
How often do you do strength train per week? What is the duration? *
Do you do any other forms of exercise? *
If you answered YES to the last question, what do you do? *
Are you currently under the care of a Physician? *
If you answered YES to the last question, why are you under the care of a physician? *
Are you currently taking any medications?  
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If you answered YES to the last question, please list the medication you are taking and how long you have been taking them.
Have you been diagnosed as Diabetic? *
If you answered YES to the last question, what type? *
Have you had any form of Bariatric Surgery? *
If yes, what type? *
If yes, when was the surgery performed? *
If yes, approximately how many ounces of food can you ingest per sitting? *
Have you ever dealt with an eating disorder that we should be made aware of? *
If yes, please explain. *
Are you currently lactating?   *
If yes, on average how many times per day? *
Are you a Vegan?   *
Do you have Celiac Disease or a high Gluten Sensitivity? *
Is there anything you'd like to disclose that we need to know to support you to be successful during the 28-Day program that we have not asked? *
If yes, what medications and frequency do you take? *
I have disclosed all necessary information that the Balanced Habits KICK START Team needs to know about me. *
I will attend the weekly journal review and weigh-ins, follow the journal requirements, and do the suggested amount of exercise. *
I promise to not expect perfection of myslef, but I do expect improvement due to my efforts. *
Will you be paying in person or via PayPal? *
Which registration option do you qualify for (honor system)? Early bird registration ends 4/30/21. *
A copy of your responses will be emailed to the address you provided.
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