GOALKEEPERS APPLICATION


NAME:      ____________________________________       
ADDRESS:____________________________________
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PHONE:    ____________________________________
E-MAIL:    ____________________________________
BIRTHDATE:__________________________________


Accountability will be a very important aspect of my workshop.  If you are considering a commitment to me, in return I will expect you to be punctual, prepared, and willing to work very hard.  If this is something you are ready to dedicate yourself to, please proceed with completing the application.

1.    What do you expect to gain from this workshop?

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2.    List 3 of your personal fitness/nutritional goals.  Be specific.

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3.    On a scale from 1-10 rate the importance of the above-stated goal. Number one being something that is least important in your life and number ten the most important.

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4.    How dedicated will you be at completing homework assignments?  Please explain.

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5.    Are you willing to keep our sessions confidential in order to  maintain the supportive/open nature of the group?

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6.    In the past, what do you believe were your roadblocks to successful weight management or fitness goals?

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Please list class day in order of preference (Tuesday nights or Thursday afternoons).  Every effort will be made to accommodate individual needs.  However, class size will dictate day assignments.  Filled on a first-come-first-served basis.

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I enter into this nutritional workshop with the understanding that I do so in good physical health.  By signing this application I fully indemnify the facilitator of this workshop et all, including but not limited, to any parties involved.  I furthermore understand all fees are due and payable upon completion of this application.  These fees are non-refundable.

Signature:________________________________________ Date:______________________________