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Inner Circle Application

Birthday
Month
Day
Year

All Vigilantech programs are for women age 18+

Multi-line address

(Fitness, weight loss, discipline, confidence, self-defense, etc.)

Have you boxed before?
Yes
No
Other
Do you have access to a heavy bag?
Yes
No

This is not a requirement for the program, but helps with building a personalized plan for you.

Which equipment would you most like to receive in your welcome box?
Boxing gloves & hand wraps
3 lb dumbbells
Power bands
Mini bands
Which commitment would work best with your schedule?
20-min workouts 6x weekly
50-min workouts 3x weekly
Something else
Has your doctor ever said you have a heart condition or high blood pressure?

Please check all that apply.

Do you feel pain in your chest when at rest, when you do daily activities for living, or when performing physical activity?

Please check all that apply.

Do you lose balance because of dizziness, or have you lost consciousness in the last 12 months?

Please check all that apply.


Please answer "no" if your dizziness was associated with over-breathing. Including during vigorous exercise.

If "no," please write "none." You may also write "decline to answer."

If "no," please write "none." You may also write "decline to answer."

Please answer "no" if you have had a problem in the past, but it does not currently affect your ability to be physically active. You may also write "decline to answer."

Has your doctor ever said that you should only do medically supervised physical activity?
Yes
No
Decline to answer
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The signature here is not signing you up for anything, or obligating you to participate in anything at Vigilantech. The information given on this form will only be used to determine if the program is a good fit, and you can participate safely. Your information is not shared or sold.

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