Successful Aging Academy – Inner Circle 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 (click to pick your birthday or Enter MM/DD/YYYY)*

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.*

References: 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 $297.00 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: *