APPLICATION AND ASSESSMENT FORM

Everyone wants to lose weight, to feel and be healthier, to achieve fitness. And many have tried all kinds of gym memberships and fitness and weight loss programs. But what we have found is consistently lacking is commitment to the hard work necessary to achieve these goals.

At the Jay Lally Core Stability Training Program, we believe that commitment is fundamental to making the life changes necessary to fitness. We want our members to succeed, and that’s why we want to recruit members to this exclusive program who share our commitment.

Please fill out this questionnaire, which will better help you – and us – determine your commitment to fitness, and whether our program can deliver the results you are seeking.

Name
Date of Birth
Address
E-Mail Address
Home Phone
Work Phone
Cell Phone
Height
Weight
Target Weight

How did you hear about our Core Stability Program?


What fitness programs have you tried in the past?


What makes you believe that you will succeed this time?


What happens if you do not succeed this time?




Please rate your past results.
(1 = Highly Dissatisfied, 5 = Very Satisfied)

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How much have you previously invested in your personal fitness?
(1 = Very Little, 5 = Considerable Investment)

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Please rate your desire to succeed in acheiving your fitness goals.
(1 = Low, 5 = High)

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5

How many days per week are you willing to commit to training?

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Please rate your commitment to changing your life using our fitness program.
(1 = Slightly, 5 = Very)

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5

Why do you want to train with Jay Lally?


Who esle is your fitness important to?



We want you to succeed. Once we have reviewed your responses, we will contact you to discuss your answers, and whether the Jay Lally Core Stability Training Program is right for you.