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Kelly White’s “Team Body Composition Challenge” Name:____________________________________________________________________________________ Address:_____________________________________ City_________________________ Zip_____________ Home Phone:____________________ Cell____________________ Email_______________________ Birth date:_______________________ Age in March:______Weight:______ Height:_______________ 1) If applicable, what is your overall weight-loss (body mass) goal? ______________________________________________________________________________ 2) If applicable, what is your body-fat percentage goal? ______________________________________________________________________________ 3) If applicable, how many inches would you like to gain/lose in your: Chest: +/-_______________ Waist: +/- _______________ Hips: +/- _____________________ 4) Team Partner’s Name:_______________________ - OR- Put My Name In the Hat (circle) 5) Additional input, if any:____________________________________________________________________ I, ______________________________ enter into this Team Body Composition Challenge with the understanding that I do so in good physical health. By signing this application I fully indemnify the facilitator of this program et al, including but not limited to, all parties involved. I furthermore understand all fees are due and payable upon completion of this application. These fees are non-refundable and non-transferable. Signature:_____________________________________________________ Date:________________________________ Do Not Write Below This Line Bodyweight pre: ________post:___________ Inches pre: Chest:__________ Waist__________ Hips:____________ Inches post: Chest:__________ Waist_________ Hips:_____________ Body Fat :pre:_____________% Lean Muscle:pre:_________lbs. Post:._____________% post: _____________lbs. Team Name:_____________________________ Additional Comments________________________________________________________________________ ________________________________________________________________________ PAID: CHECK #/AMOUNT:__________________ CASH/AMOUNT:_____________________
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