let’s get started. Name * First Name Last Name Email * Date of Birth MM DD YYYY Program Selection * Learn Movement Learn Principles Train Hard Preferred Program Start Date (Must choose a future Monday) * Must choose a future Monday MM DD YYYY Mobile * Country (###) ### #### Emergency Contact Name First Name Last Name Emergency Contact Email * Emergency Contact Phone * Country (###) ### #### General Health This screening form is based on Stage 1 of the ESSA Adult Pre-Exercise Screening System (APSS). If you select "Yes" to any questions below, we may require you to provide clearance from your medical practitioner before commencing exercise. Has your practitioner ever told you that you have a heart condition, or have you ever suffered a stroke? * Yes No Do you ever experience unexplained pains or discomfort in your chest, at rest or during physical exercise? * Yes No Do you ever feel faint, dizzy or lose balance during physical activity/exercise? * Yes No Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? * Yes No If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months? * Yes No Do you have any other medical conditions that may require special consideration for you to exercise? * Yes No I agree to notify my Kallos Coach in the event of an injury or change in medical status that could impact exercise. * Yes I have read and agree to the program terms and conditions. * www.kallosalethia.com/terms-of-service Yes I have read and understood the Kallos Alethia Privacy Policy, and I consent to the collection and secure storage of my personal and health information, including sharing relevant data with third-party providers (such as TrueCoach and Stripe) for service delivery. * www.kallosalethia.com/privacy-policy Yes If you’re unsure whether it’s safe to participate in this program due to a medical condition or recent health event, please delay submission and contact us at hello@kallosalethia.com Thank you!
