Les Mills Mid-Atlantic, Inc. Assessment Cover Sheet Please send this with your assessment DVD Name: __________________________________________ Address: ________________________________________ City: _________________________ State: _____________ Zip: ________ Phone: ( ) ________________________________________ Email: ____________________________________________ Fax: ( ) __________________________________________ Club Name: ________________________ Club Ph: ( ) ________________ Group Fitness Director’s Name: ____________________________________ Circle the appropriate Les Mills program for this assessment: BODYPUMP® BODYCOMBAT® BODYSTEP® BODYATTACK® BODYJAM® BODYVIVE® RPM® BODYFLOW ® Date Trained: __________________________________ Name of Trainer: _______________________________ Grade: _____ Location of Training: ____________________________ Please provide details of your Teaching Experience: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Class Time Slot: ______________ # of participants in class: _____________________ How did you feel about the class you taught? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ List the teaching goals you are now striving to achieve: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________