Badass Booty Program Intake Form

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Thank you for your interest in our program! The following information will help us support you through it.

Email *

First Name *

Last Name *

Phone Number *

Date of Birth *

YYYY

Preferred Pronouns *

How did you hear about DAM? If a friend referred you please share their full name so we can thank them! *

What's your favorite way to move your body?

I'm interested in... *

the fully guided program

the partially guided program

the self guided program

Required

When do you plan to get started with the program? *

Is it ok to contact you about upcoming DAM Fit deals and offerings? We promise to respect your info! *

Yes

Has your doctor ever said that you have a heart condition or high blood pressure and that you should only perform physical activity recommended by a doctor? *

Yes

In the past month, have you had chest pain while at rest, during daily activities, or when you do physical activities? *

Yes

Do you ever lose your balance because of dizziness (not associated with over breathing or vigorous exercise) or have you lost consciousness in the last 12 months? *

Yes

Do you have a bone, joint, or soft tissue problem that currently affects you and could be made worse by a change in your physical activity? *

Yes

Have you been diagnosed with another chronic medical condition that currently affects you and that you are currently taking medication for? *

Yes

If you answered yes to any of the above questions or have anything else we should know about your body please elaborate below.

What do you dream about being able to do with your body?

Emergency Contact Name & Number *

By typing your name below, you are effectively providing your signature (for yourself or your dependent if they are under the age of 18). You are indicating that all the information on this form is true and accurate, to the best of your knowledge, and you are accepting the terms of the waiver below. *

Send me a copy of my responses.

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