First name
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Last name
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Email
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Confirm email
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How did you hear about us?
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What is your primary goal with this program?
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Please be as specific as possible e.g. if weight loss is your primary goal, how much weight & in what time frame?
Do you have any health concerns?
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When do you want to get started?
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If more than 1 week away please do not submit your application at this time
What is the best number to reach you on if we need to call you?
Please confirm the program you're applying for.
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Basic
Essential
Preferred coach
Jason Ackerman
Roz Ackerman
No preference
Pricing
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$270.00 - Every 3 months
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