Let’s PUSH together.

Thank you for your interest in joining Lighthouse for Health & Wellness in our quarterly 6 week challenge. Please fill out the information below to get you started with your 6 week challenge. More information will come to your email soon regarding the challenge. If you have any questions please reach out to our email info@lighthouseforhw.com.

Name

First Name

Last Name

Phone

(###)

###

####

What is your current weight range?

What are your major goals/targets?

Weight Loss/Gain

General Fitness

Muscular Endurance

Nutrition/Diet

What are your top 3 fitness and nutrition goals?

Do you have a specific event/date you are working towards? If yes, what is the date and event?

How would you describe your current knowledge of exercise and fitness training?

If you currently exercise, would you say your routine is:

How motivated are you to achieving your goals?

What, if any, are your expected barriers toward your exercise program?