EmailMe Form - Fitness model for exercise DVD

Name *

First Last

Age *

Mobile Number *

### - ### - ####

Email Address *

Height *

Current weight *

How many days a week do you workout? *

What type of workouts do you engage in (cardio, yoga, weight-lifting, aerobics, etc)? Please explain. *

Do you participate in any recreational sports or activities? If so, please explain. *

Any past surgeries? If so, please explain. *

Any past or current injuries? If so, please explain. *

Do you take any type of medication? If so, please explain. *

Any history of dizziness, chest pain or fainting? If so, please explain. *

Do you know of any reason why you should not engage in physical activity? If so, please explain. *

Do you smoke? *

Yes

No

Do you drink? *

Yes

No

Please upload a current photo of yourself (taken within the last 2 weeks) *

Camera phone photos are acceptable. Make sure it's a full-body, clear and well lit photo. All info submitted is strictly confidential. We will not share your information.

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination at any point in the future if I am hired.

Do you agree with the terms and conditions? *

Yes, I agree.

Type full name *