2019 Pilot Program
First Name *
Your answer
Last Name *
Your answer
E-mail Address *
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Phone Number
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What is your primary goal?
Other goal, please specify
Your answer
Current weight (Optional, but will help to specifically calculate your goals)
Your answer
The success of this program is based upon your willingness to implement changes. This is not a one-sized-fits all program, it is personalized to you. What you put into this program, is what you will get out. At this time are you willing to dedicate the time necessary and be honest and open-minded about making changes?
Commitment: I agree to fill out weekly check-in forms, read, interact and apply what is discussed in my weekly coaching e-mails/texts, and set up monthly calls with the Kansas City Dietitian. Type your name below to indicate agreement.
Your answer
For my weekly coaching sessions I prefer:
Congratulations! I am so excited to start this journey with you. Within 24-hours of submitting this form you will receive an invoice, if you do not receive the invoice please check your SPAM. Your program will start the Sunday following your successful payment. Questions? Email thekansascitydietitian@gmail.com
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