First Name
Last Name
Email
*
Phone
*
Where are you located? (This is so that we can connect you with the right WILCOX team to support you.)
Bangor, Maine
Brunswick, Maine
What are your health and fitness goals ?
I want to gain energy
I want to feel better
I want to gain confidence
I want to be able to enjoy being more active - ex: hiking, biking, boating, etc..
I want to learn how to eat better
I want to be able to do things (like climb a flight of stairs or walk up-hill) without becoming winded
I want to increase my mental focus
I want to feel better about myself
I want to be able to fit into the clothing in my closet that no longer fits
I want to lose body fat/weight/inches from my body
I want to add lean muscle, and strengthen and tone my body
Other:
Others ( Health and Fitness Goals)
Do you currently exercise? (Don't worry - no judgment here.)
Almost never
Inconsistently (a few times a month)
Regularly and consistently (a few times a week)
Other:
if others, mention it here :
WHY is it important for you to commit to healthy living? (Check all that apply.)
To be able to show up as the best version of myself.
To have the energy to do all the things I love doing.
To be a better parent for my kids.
To prevent future health complications.
For stress-relief.
To do something good for myself.
To have more confidence.
To feel good about myself.
Other:
If others, mention it here :
On a scale of 1-10, how committed are you to achieving these health and fitness goals? 1= not committed at all. 10= totally committed.
1
2
3
4
5
6
7
8
9
10
If your commitment level is below an 8... why? What's holding you back?
What is the most recent thing you've tried doing to lose weight and/or get in better shape?
A diet
An exercise program
A diet and an exercise program combined
It's been a long time since I've tried anything
Other:
If others, indicate here :
What do you want to get out of beginning a new, and incredibly effective, body transformation program?
I want to look and feel better, more relaxed, confident, and present in the moment
I want to take control of my health and strengthen my immune system
I want to be a better role model for the people I love
I want to re-ignite the fire in my relationship
I want to feel stronger, more flexible, mobile, balanced, and pain-free
All of the above
Other:
If others, write here :
What do you feel is the biggest thing standing in your way of becoming the best version of you? What has been your "achilles heel" when it comes to having the body and health you most want to have?
Anything else you want us to know? Do you have any health concerns or medical conditions we should make our trainer team aware of?
A referral is the ultimate endorsement - the ultimate sign of trust. We're so grateful that so many trust us, and we always want to make sure to thank them for their referrals. Please tell us who referred you, or how you heard about us. Thanks!
Where do you live? City, State, please.
I understand that the next step is to process my payment for the 2-week TRIAL Program and then schedule my Program Orientation Session.
YES! Let's do this!
Submit