Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Are you a current or former member of the US Military or a military dependent?
*
If you checked YES to the question above, please provide the highest rank you acheived or are currently. If you are a military dependent, type "dependent".
If you have served in the US Military, please check which branch(es) you have served in.
Are you a current or former First Responder or First Responder dependent?
*
YES
NO
If you checked "YES" to the question above, please type your current or highest rank as a First Responder or if you are a First Responder dependent, please type "dependent".
If you have been a First Responder, please indicate what type of First Responder you have served as.
Gender
*
MALE
FEMALE
TRANSGENDER
Age
*
Height (feet)
*
3ft
4ft
5ft
6ft
7ft
Current weight in pounds
*
If you are currently serving in the military or as a first responder, did you "pass" your last physical fitness performance test?
YES
NO
Not Applicable
Which statement best descibes your phycial fitness today?
*
I consider myself VERY physically fit.
I consider myself physically fit.
I consider myself somewhat physically fit.
I consider myself NOT very physically fit.
I consider myself extremely unfit physically.
Which statement best describes your phsycial composition?
*
I am at a healthy weight and body composition and I want to maintain where I am at right now.
I am at a healthy weight, but I would like to reduce my body fat.
I could stand to lose 5-10 pounds.
I need to lose 15- 25 pounds.
I need to lose 30-50 pounds.
I need to lose 60-80 pounds.
I need to lose 90-100 pounds.
I need to lose over 100 pounds.
Which statement best describes your current eating and drinking habits.
*
Very healthy, no changes needed.
Somewhat healthy, but I could eat healthier.
I don't have a healthy diet right now, I need to make major changes.
I thought I was eating healthy, but I continue to put on weight.
Please type below what your fitness and health goals are for your 30 Day Program
Are you currently following a diet? If Yes, please describe what diet you are following.
Is there anything else you feel like your FTW Cadre needs to know about? If so, list here.
