Nominee Details *

First Name

Last Name

Name of person filling form (If you are nominating someone else)

First Name

Last Name

Phone Number (of nominee) *

(###)

###

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Phone Number of person filling form (if you are nominating someone else)

(###)

###

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Could the nominee easily afford to hire a personal trainer, nutrition coach and pay for a premium gym membership? *

Yes

No

Unsure

Could the nominee commit to completing our 12 week program?

Yes

No

Unsure

Does the nominee have any health conditions or factors that we should be aware of to ensure appropriate modifications can be made to our program for their safety and well-being? *

Yes

No

Unsure

Level up requires participants to complete 4 workouts a week (roughly one hour each). It will also require attendance of small group sessions every two weeks. the nominee have any limiting factors that might prevent them from participating? (check all that apply)

Transportation

Childcare

Can't attend small group sessions

Other (please specify below)