Congratulations you are one step closer to starting our 12Week Shape Up
Filling in this questionnaire, will help us understand more about you and what your goals are too.
I look forward to your response.

Stephanie Ferretti
Powerhouse Gym Director
Email *
Your name *
Your contact number *
Your age *
Your height (cms) *
Your current weight *
How satisfied are you with your current eating? *
Not very
Im happy with it
Is there foods that you do not like? *
Please list the foods that you do like and would like to continue to eat? *
Do you have a goal yourself?
Do you have any current injuries/limitations? *
If yes, please state what injuries/limitations
How happy are you with your physique and fitness at the current moment
Very Happy with my Physique
Clear selection
What parts of your body would you like to focus on improving?
Column 1
all over strength
Least favourite body part to train *
How many times are you able to commit to training for your goal? *
Both presented and pre-read material
Do you take any medication or supplements? *
If you are, please state what medications/supplements.
Are you a smoker? *
How many drinks do you have per week? *
What is your motivation to start your 2020 shape up? *
How can we keep you on track? *
Are you ready to commit to your 12W Shape Up? *
Powerhouse Gym t&c's
Please read carefully.
All eating plans are tailored by the results submitted to the Powerhouse Gym.
The staff and management of Powerhouse Gym are not responsible for you not achieving your goal if you do not put in 100% commitment to all eating plans, and training programs.

- To confirm your commitment to this challenge, please proceed to our online store to complete your purchase.
- All Check In's are Online only.
- cCheck in is week 3, 6, 9 and final week is on a Saturday of starting your body transformation.
- Weight in, measurements and photos are to be completed and sent by email the night before your check in too.
- Further tailored eating/training program will be tailored only after submission of photos (front, side, back)
- Powerhouse Gym reserves the right to refuse to work with an applicant due to the applicant not checking in for the program for a consecutive 2 weeks and showing a insolent and uncooperative behaviour towards management/staff. This will result in immediate forfeit of their downpayment.
I sign and agree to the t&cs as mentioned above *
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