Name First Last Date of birthMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email OccupationMobile numberDate of BirthHeightWeightEmergency contact name & mobile Separate tags with commas How did you hear of Dan Roberts™ retreats A personal recommendation TV / Newspaper / Magazine Interview about Dan Google search Instagram (@teamdanroberts) Hotel online advert Hotel social media/adverts Other What injuries do you have?Do you suffer from any of the following? ME High blood pressure Low blood pressure Diabetes Disordered eating BDD ADHD Raised cholesterol Anxiety Liver or Kidney conditions Digestive problems Any heart condition Epilepsy Hernia Osteoporosis Arthritis Asthma Cramps Muscular pains Do you smoke? No Occasionally 40+ a week How much do you drink? Occasionally 10+ units most weeks 25+ units most weeks What medications are you on? Separate tags with commas Do you have any infectious diseases? No Yes Have you been recently hospitalized? No Yes Have you recently had surgery? No Yes Are you pregnant? No Yes Waiver of Liability: Please scroll through fully and TYPE your name at the end.*We assume no liability for persons injured following our exercise or nutrition advice. In addition any Martial Arts or combat training is only available to those who waive all liability to any accidents or injury. If any medical or other conditions arise that could affect your training with us, you shall let us know immediately by email. If you have any doubts, please consult your doctor prior to physical activity. All exercise, nutritional and well-being advice given to you by any persons directly associated with Dan Roberts, Dan Roberts Training Ltd & Dan Roberts Enterprises Ltd is taken at your own risk. By typing your name and today's date after this statement you agree by these terms. This is required. Please type your full name and date right here....DELETE THIS AND TYPE YOUR NAME & DATEPlease read and sign aboveDid you type your name and date the liability waiver above?* Yes Which Retreat would you like to book?7 day Miami3 day Portugal (small groups)Bespoke (Dan comes to you - £2,500+ per day)Are you coming alone or bringing a friend ? (there are no extra coaching charges)What dates do you wish to travel ?How flexible are you with your dates?What are your current health, fitness & wellbeing goals?Why are these goals important to you?What training do you currently do?If you would like us to contact your last trainer, please give details.What are your expectations?Which exercises/activities do you love doing and why?Do you want help with stress? No thank you Maybe Definitely Do you want help with body image? No thank you Maybe Definitely Is there anything else we should know?Are you interested in any of our specialist services in London ? Movie Role Prep Fashion Model Conditioning Pro Athlete Consulting 100 Day to Athlete Programme 12 month Wellness Reset Package Martial Arts / Combat instruction Post Natal Care Online Training What specific additional questions for Dan about the retreat?Dan will be calling you within the next 72 hours. What times/days are good for you?*
