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3 Free Months of Weight Watchers + $75 Gift Card for in-person, $50 gift card for virtual
Fill out the form below if you are available to attend
5 Free Weight Watchers Sessions, 1 per week
Starting: Wednesday September 1st, 10am
Location: 319 Franklin Ave Suite 111, Wyckoff, NJ 07481
OR
Starting: Friday August 27th, 2pm EST
Location: Virtual
2021-Jul Weight Watchers
Name
*
Name
First
First
Last
Last
Phone
*
Email
*
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Age
*
Gender
*
Male
Female
Occupation
*
Are you currently Pregnant, trying to become Pregnant or Breastfeeding?
*
Yes
No
Have you lost more than 10lbs in the last 3 months?
*
Yes
No
Do you want to lose at least 11 or more pounds?
*
Yes
No
Do you currently suffer from any of the following?
*
Eating Disorder`
Diabetes
Food Allergies
Colitis
None of the Above
Height & Weight
Feet
*
Inches
*
Weight (lbs)
*
Do you agree to answer weekly surveys?
*
Yes
No
Are you currently following any weight-loss plans or diets?
*
Yes
No
Have you ever followed a Weight Watchers plan before?
*
Yes
No
Are you open to following a Weight Watchers Plan?
*
Yes
No
Do you have access to an iPhone using iOs 12.0 or Higher?
*
Yes
No
What is your Household Income?
*
Under $40,999
$41k-$65k
$66k-$124k
$125k+
What is your Highest level of Education?
*
High School Grad
Some College/ Trade School
College Grad
Some Post Graduate Work
Post Graduate Work +
Do you have access to a scale?
*
Yes
No
Do you agree to attend a weekly 30-40 minute in-person (for Staten Island and SF) or online (for Virtual Workshops) weight-loss group workshop lead by a WW Coach?
*
Yes
No
Do you agree to sign an NDA (Nondisclosure Agreement)
*
Yes
No
If you are human, leave this field blank.
Submit