Successful Aging Academy – Standard Application Form

Completing this form is your first step to getting started with us…and to finally changing your entire aging process.

Gender

Male Female

Birthday *

Please hold the CRTL or Command key and choose all the topics below you have an interest in hearing more about. NOTE: As part of the SAA curriculum, you ALREADY receive access to coaching in the following areas: Nutrition, Resiliency Training, Cardio-Vascular Coaching, Strength Training, Balance & Mobility Training, Habit/Lifestyle Change. *

I agree to pursue my goals with all the passion expected of me and understand this as a duty and obligation to myself, family and friends. Please Initial. *

I understand I will have access to the following to help in my success and will allow time to take advantage of them: 1) Weekly “office hours” to answer email, text and Voxer inquiries, weekly groups coaching calls, newsletter delivery (includes any bonus materials). Please initial. *

I agree NOT to share, duplicate or otherwise disseminate the SAA program information to individuals NOT enrolled in the Successful Aging Academy. Please initial. *

I understand this is intended to be a 12 month curriculum and promise to make a commitment to completing this program. Please Initial.*

Referrals: Please list others who you feel might benefit from the SAA curriculum. We will need name, email and/or phone number.

I understand I will be billed monthly to the card provided through our secure form. The monthly coaching fee is $97.00 unless otherwise agreed upon*. This fee will never increase as long as I am a coaching client in good standing. I also understand there is a four month minimum. *While I can cancel at any time after the initial four months, I understand there are no refunds for the current or any previously completed month's Coaching Fees. A 30 day notice is required for cancellation. Please type out your name: *