Sign Up for RealSteps – RealSteps for real health

Your Name*

First Last

Your Age Range*

Your Gender*

Do you have any current diagnosed medical (mental health, physical) conditions?*

Yes

Please explain

Are you or have you been in the past under the care of a physician for any chronic illness?*

Yes

Please explain

What 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?*

1-3

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?

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 Fall 2022

Coupon

Total

How would you like to pay?*

Credit Card

PayPal

Credit Card Information*

Card Details

Cardholder Name

Payment Method*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

RealSteps Terms & Liability Waiver

Rules*

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 body

Please 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*

This field is for validation purposes and should be left unchanged.

Create account

The cost to participate in RealSteps is $150 (USD)

RealSteps Terms & Liability Waiver

Want to participate in the next round?