Sign Up for RealSteps Sign up for the Spring 2023 round of RealSteps. If you've participated in a previous round, login first to grab your previous information. "*" indicates required fields Step 1 of 3 - About You 0% Your Name* First Last Your Age Range*Under 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerYour Gender*MaleFemaleOtherPrefer Not to AnswerDo you have any current diagnosed medical (mental health, physical) conditions?* Yes No Please explainAre you or have you been in the past under the care of a physician for any chronic illness?* Yes No Please explainWhat are you most unhappy about related to your mental and physical health?*How many times have you tried to go on a diet to lose weight?* 0 1-3 5+ What lifestyle changes have you been successful in?*Why do you want to be part of the RealSteps 4-Week Challenge?*What do you hope to accomplish during the RealSteps 4-Week Challenge?*Anything else you would like us to know about you? Create accountTo participate in RealSteps, you'll need to create an account. This will give you access to all the content and materials you'll need, as well as give us a way to contact you. If you already have an account, please log in.Email* Username* Nickname*This name will appear on posts or comments Password* Strength indicator The cost to participate in RealSteps is $150 (USD)Your credit card will show a charge from WDMENTALHEALTH (Wendi's therapy business). Please enter your payment information below.RealSteps Spring 2023Coupon Total How would you like to pay?* Credit Card PayPal Credit Card Information*Card Details Cardholder Name Payment Method*PayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country RealSteps Terms & Liability WaiverRules* I agree to follow the rules of the RealSteps 4-Week Challenge• No negativity • No trolling or rudeness • Only show support to your fellow RealSteppers • No weighing yourself • No bullying • No talking about diets or your weight • No being rude to yourself about your body • Your job in this group is offer support, encouragement and find connection • Have fun and learn to feel good in your bodyPlease Read and Sign This Consent Form. Acknowledgement of Health: I declare myself physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in the RealSteps 4-Week Challenge. I acknowledge I have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in any dietary changes. I recognize it is my sole responsibility to obtain an examination by a physician prior to involvement in any exercise or nutrition program. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this 4-Week Challenge. I acknowledge I am doing so at my own risk. I acknowledge and agree no warranties or representations have been made to me regarding the results I will achieve from this program. I understand results are individual and may vary. I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against RealSteps 4-Week Challenge, its respective representatives, executors, and/or assigns. By submitting this form electronically, I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS. Participant Signature* Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
