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:________________________________

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:_____________________