Nakoma Application Form "*" indicates required fields Step 1 of 2 50% 1. Name* First Last 2. Gender*FemaleOther3. Date Of Birth* MM slash DD slash YYYY 4. Address* Street Address 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 5. Contact Number*6. Email* 7. Why are you interested in coaching at this time in your life?*8. What are your primary goals for seeking Nakoma wellness services? Select all that apply.* Improving overall health and lifestyle Achieving body transformation Enhancing physical activity levels Boosting mental well-being Attaining a better work-life balance Following a balanced diet Other Please provide a brief description of your goals.*9. Have you worked with a wellness Coach in the past?* Yes No Please explain.*10. How would you rate your exercise/gym experience?* Beginner - I don't know what I'm doing Intermediate - I know what I'm doing but have no real direction Proficient - I know more than the basics, but I have a ways to go Advanced - Yes, I know there are different styles of deadlifts 11. What have been your main struggles in your health and fitness journey? Select all that apply.* Consistency in exercise routines Maintaining a balanced diet Overcoming motivational barriers and staying accountable Managing time effectively for workouts and balancing with other life commitments Dealing with injuries, physical limitations, or stress-related issues Other Please explain.*12. Our personalized coaching services range from $200-$350 per month. Are you ready to invest in your well-being?* Yes, I'm ready No, not at this time Need more information 13. Physical Limitations (If Any)14. Any Questions?15. Please tell us how excited you are to move on to the next step!!!! (1 Not excited at all, 5 being very excited)* 1 - Not Excited at all 2 - Slightly excited 3 - Somewhat excited 4 - Excited 5 - Very Excited By checking the box, you agree to the Privacy Policy and understand that any data you share is protected and secured.* I agree to the privacy policy.
