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Television Series Application Form
Slender Wonder is looking at the possibility to film a reality television series.
The series is for candidates who wants & needs to lose weight between the range of 10 – 40 kilograms.
The purpose of the series will be to film a Slender Wonder patient’s 16-week progress on the programme and share this with the viewers.
In the interim we are looking for possible candidates to enter. Once the concept is finalised we will start with interviews and choose the best suitable candidates.
Criteria:
1. Someone who isn’t currently on Slender Wonder and hasn’t been in the past. 2. You must be comfortable with camera crew filming you and your private life
from time -to time. 3. You must a have clear criminal record. 4. Be comfortable in front of the camera and not be camera shy. 5. Your start weight and progress will be made public on several platforms. 6. You must be over the age of 18 7. The candidate must be able to speak Afrikaans fluently 8. You must be willing to travel to your chosen Slender Wonder doctor and to
where the production team requires you to do so. (Own transport required) 9. Candidates must be from the Johannesburg or Pretoria areas
In order to be considered a candidate please complete the form.
Please note: The series hasn’t been confirmed as yet, as soon as it has been confirmed & finalized we will get in touch with you.
Only suitable candidates will be contacted for an interview.
Please e-mail your form as well as photograph to [email protected]
**Only one full length photo is needed**
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Please carefully answer the following questions below:
1. Name and Surname:
2. Area:
3. Email:
4. Cell:
5. Tel:
6. Current occupation:
6.1 Does your occupation require you to travel a lot and/or eat out a lot?
6.2 Do you work night shifts?
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6.3 Do you frequently fly to other countries?
7. How much do you weigh currently?
8. How tall are you, (height)?
9. Age:
10. Male/Female
10.2 Will the people you share your home with be supportive of your journey on Slender Wonder?
10.3 Who prepares the food in your home environment?
11. What is your residential area?
12. What amount can you contribute to the Slender Wonder programme:
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13. What are your exact weight loss goals?
14. Why do you want to lose weight?
15. How do you consider weight to be a problem for you?
16. How sedentary (inactive) versus active is your lifestyle? In other words, what types of exercise do you get each day? Doing what, how often and when?
17. On a scale of 1 to 10 please choose a number to show how much you DESIRE to lose weight?
18. On a scale of 1 to 10 please choose a number to show how much you BELIEVE you can lose the weight you want lose
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19. What price (not in money) are you willing to pay to lose weight? In other words, what are you willing to DO to lose the weight you desire to lose?
Weight Loss History:
20. What have you done to lose weight in the past? How long did you keep the weight off?
21. What started you gaining again?
22. What formal or informal diets have you been on in the past? Did they work? For how long?
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23. How much weight did you lose? How soon did you gain the weight back?
24. Name and Phone of Primary care doctor?
25. Do you smoke?
26. Do you drink alcohol? What, When, how much and how often?
26.1 Do you drink soft drinks/fruit juices/diet cool drinks/protein shakes/yoghurt drinks? How many per day?
26.2 Do you add sugar to your drinks?
26.3 Do you use sweeteners? Which ones?
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27. Are you currently on any medication/chronic medication? Specify?
Cortisone Thyroid medication
Anti-depressants Oral Diabetic medication
Sleeping tablets Insulin
Any other psychiatric medication Fat burners
The contraceptive pill or patch Appetite suppressants
Mirena "Diet" tablets
Other:
28. Do you have any/Are you aware of any health problems i.e kidney, heart, high blood pressure, any major operations, ect
28.1 Questions for women
Are you pregnant?
Are you breastfeeding?
Are you menopausal?
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Are you planning a pregnancy?
Have you had fertility treatment?
Do you suffer from PCOS-polycystic ovarian syndrome.
29. What are some pleasant experiences and images of you?
30. What are you especially good at, and what do you enjoy doing?
31. How many meals a day do you eat? Please describe in detail?
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32. Do you snack? If yes, on what and when, where, and how much?
Weight Loss Questions – General
33. Do you eat between meals? If yes, what, when, where and how much?
34. Do you eat fast or slowly?
35. What tastes do you especially like or crave?
36. What foods do you like?
37. What foods do you dislike?
38. What are your favourite foods?
39. Do you skip meals?
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40. Do you have difficulty saying no to yourself?
41. What is your favourite meal of the day?
42. What is your biggest meal of the day?
43. Who prepare your meals?
44. What time do stop eating at night?
45. Do you eat more at night than during the day?
46. Have you ever had counselling or therapy concerning your weight and /or relationship with food?
47. Do you have any fears about losing a large amount of weight?
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48. Do you eat out a lot?
49. Do you overeat? What foods do you overeat on?
50. When and where do you overeat?
51. Why do you think you overeat?
52. Any other information about you we should know?
53. Do you drink a lot of Soda?
54. Do you eat or drink anything with Aspartame in?
I have answered all questions truthfully.
Signature: ___________ Date: _____________
For any queries about this application form please contact: [email protected]
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