EmailMe Form - International Coaches Registration

Do you live in the United States? *

Yes

No

Event *

Youngsville, LA -- May 26th-29th

Punta Gorda, FL -- June 9th - 12th

USA Passbook ID

Level *

Level 1

Level 2

Level 3

Email *

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone

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

Mobile Phone *

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

Do you have a fever or have you felt hot or feverish recently (14-21 days)? *

Are you having shortness of breath or other difficulties breathing? *

Do you have a cough? *

Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? *

Have you had any loss of smell or taste recently? *

Are you in contact with any confirmed COVID-19 positive patients? *

Is your age over 60? *

Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *

Have you traveled in the past 14 days to any regions or countries affected by COVID-19? ( as relevant to your location) *