Let's get you into the next eight weeks.

First name *

Last name *

Email *

Phone number *

Are you a current Halligan's Fitness member? *
YesNo / returning

Challenge option *
Standard Challenge $250Personalised Challenge $330

Emergency contact name

Emergency contact phone

Exercise experience

Goals for these eight weeks

Health screening (new and returning clients)

Heart condition or stroke?
YesNo

Chest pain during rest or exercise?
YesNo

Faint, dizzy or lose balance during exercise?
YesNo

Muscle, bone, joint or injury concerns?
YesNo

Currently pregnant, or given birth in the last 6 months?
YesNo

Anything else we should know about your health or injuries?

Current members ? any updates we should know?

I acknowledge and accept the participation agreement and wish to take part in The Identity Shift Challenge.

Full name (as your signature) *

Date *