Summer Survival Programme Registration & Payment

Please fill out your health questionnaire and pay using the Paypal button below.

Select your entry fee by using the drop down price menu.
Early bird new clients are $47 if you sign up before 5pm Thursday 24th December! Payments after this will be at full price of $97.00.
After your payment is successful, we will be sending out your program material before December 24. Please contact us if you have difficulty. Otherwise direct payment to our account : No Compromise Fitness Management LTD, Westpac 03 0435 0697863 00.
Please fill out your health questionnaire

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Name*

First Name

Last Name

Email Address*

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Phone*

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Facebook Name

For video messenger chats

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What Do You Need Help With Right Now?*

Bodyweight

Autoimmune condition

Emotional stress

Physical pain

Gut issue

Menopause

Depression/Anxiety

Poor Sleep

Other

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Please list any other previous or current health issues

Such as glandular fever, hepaptitis, herpes infections, strep throat, acne, psoriasis and other skin issues etc

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Have you had or currently have mercury fillings?*

Yes

Do you smoke?*

Yes

Are you a previous smoker?*

Yes

Do you work with chemicals such as pesticides & herbicides?

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Stress

Please list what your biggest stress is right now ie work, relationships, kids etc

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Historic Emotions

List any unresolved emotional stress here

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Have you had surgery in the past?

If so, list here.

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List any medications that you take

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Bowel Movements*

Easy Daily elimination like clockwork

Daily but irregular timing

Very irregular

Loose stools

Constipation

Family History

Please list any diseases that you are aware of with your family members

Grandparents

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Blood Related Uncles & Aunties

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Parents

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Siblings

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I accept that all data collected is strictly private. I understand that best to my knowledge I am submitting information that is true & correct. I understand the Steve Jennings holistic health Coach will provide dietary and other lifestyle instruction to aid me in my health objectives. I understand that results vary based on the individual. I understand that during a healing phase, it is normal to expect a “healing crisis,” where detox symptoms can appear initially. Steve Jennings Holistic Health Coach will not coach me on medication dosages such as anti depressants, anti anxiety medication and immuno suppressants. I will not hold Steve Jennings Holisitic health Coach responsible for accidental injury.

I agree

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Please Make Your Payment Below. We Will Email You As Soon As We Receive Payment.

Entry Fee