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Thank you for your interest in Lighthouse for Health & Wellness. Please fill out the information below to get you started on your FREE All trial. If you have any questions please reach out to our email info@lighthouseforhw.com.

Name

First Name

Last Name

Phone

(###)

###

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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?