Name: *

Phone number: *

Email: *

What is your MAIN GOAL by participating in the KICK START? *

How many meals/snacks do you currently consume on average per day? *

How often do you do cardiovascular exercise per week? *

For your cardiovascular exercise, what is the normal duration? *

How often do you do strength train per week? *

For your strength training, what is the normal duration? *

Do you do any other forms of exercise? *

Are you currently under the care of a Physician? *

Are you currently taking any medications? *

Have you been diagnosed as Diabetic? *

If diagnosed as Diabetic, what medications and frequency do you take:

Have you had any form of Bariatric Surgery? *

If you had Bariatric Surgery, what type did you have and when was the surgery performed?

If you had Bariatric Surgery, 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?

Are you currently lactating?

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 has not been identified above?

I have disclosed all necessary information that the Balanced Habits KICK START Team needs to know about me. I understand what is expected of me during this 28-Day program and commit to the suggestions and guidelines. I will attend the weekly journal review, follow the journal requirements, do the suggested amount of exercise. I will read the emails coming from my Food Coach. I promise to not expect perfection, but I do expect improvement due to my efforts. Fee for Kick Start is non-refundable. Type your name below to indicate that you agree with these statements.

Program Fee: $119 Memb.; $ 149 Non-Memb.

Birthdate: *

Mailing Address: *