Online Fitness Coaching

First name

Last name

Ideal Start Date

Date of Birth

Month

Day

Year

Have you ever worked with a coach?

Yes

What do you want to achieve through this program?

How important is it to you to achieve this goal? (Scale 1-10)

Have you been cleared by your physician to pursue fitness and nutrition coaching?

Yes

Disclaimer: Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

By checking this box, you agree with and understand the statement above.

By submitting this form you are agreeing to be contacted by Resilience Fitness & Nutrition and its representatives via email.