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New Client Intake Form
Thank you for your interest in Shine Bright Fitness. Please complete and submit this form and someone will contact you to schedule a new client evalutation.
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Primary Parent/Guardian Full Name
*
Your answer
Primary Phone Number
*
Your answer
Primary Email(To be used for appointment notifications)
*
Your answer
Secondary Parent/Guardian Name
Your answer
Secondary Phone
Your answer
Secondary Email
Your answer
Client Full Name
*
Your answer
Client Full Address
*
Your answer
Client Date of Birth
*
Your answer
For regional center members, please enter your case manager's name and email below.
Your answer
Additional Notes
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Preferred Session Times
After the evaluation, we will match you with a trainer. Please let us know times during the week when you are available for sessions. This can be changed at any time.
Requested Amount of Sessions
Choose
Once per week
Twice per week
Three or more times per week
Day and Time Preference
(Please List Each Day and Time You Want to Request
Ex. Monday 3pm-5pm, Saturday 10am-1pm)
Your answer
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