Pittsfield Family YMCA: Personal Training Services

Transcription

1 Pittsfield Family YMCA: Personal Training Services I would like to purchase the following Client s Name personal training package with personal trainer : Trainer s Name 1 Session, $40 2 Sessions, $80 5 Sessions, $ Sessions with annual membership, $ Sessions with monthly membership, $350 plus $60 monthly membership fee, totaling $410. First payment must include $35 for the training session and the full cost of the month membership totaling $95. I would like to pay for the sessions the following way: The full cost for all training sessions $ Pay per session Set up an automatic payment plan, EFT I agree that I am healthy and I am able to participate in the personal training program at the Pittsfield Family YMCA. I understand that at any point my personal trainer may request to get clearance from my doctor for any reason he/she feels necessary. I understand that I am responsible for the above payment and session obligation. Personal training sessions will start on / / and end on / /. Trainer s Signature

2 Page 2 PERSONAL TRAINING POLICY Thank you for choosing personal training services through the Pittsfield Family YMCA. Here are some guidelines so that the personal trainer and the client can work together as a team. 1. Cancellation of a personal training appointment 24 hours prior. It would be appreciated that cancellation of the personal training appointment be made 24 hours prior to the appointment. The session will be made for another time when it is convenient for both the trainer and the client. 2. Cancellation of a personal training appointment within 24 hours. If an appointment is canceled less than 24 hours prior to the scheduled time, the Y is NOT obligated to make up the session. 3. If you do not show up or call within 24 hours, the client will be charged for the missed personal training session. 4. Personal trainer will wait for 15 minutes after scheduled time. After this time, the trainer will not continue to wait, and client will be charged for an entire training session. 5. Please show up ready and on time for your appointment so the session can start at the expected time. 6. For your own comfort, wear gym clothes, such as sneakers, shorts, wind pants, T-shirt, etc. so that you are as comfortable as possible when exercising. 7. Please bring water. Staying hydrated is very important. 8. After you pay for your "PT" sessions, please bring the receipt to your personal trainer. Doing so verifies payment. 9. Finally and most importantly, have fun and enjoy your PT time. Trainer s Signature

3 Page 3 HEALTH/MEDICAL HISTORY QUESTIONNAIRE Name: : Birth date: Gender: M/F Address: Street City State Zip Address: Phone: Emergency Contact: Phone: _ Relationship: Primary Physician: Name: Phone: This form is intended to obtain relevant information about your health that will assist the staff in helping you with your program. This is confidential please answer all questions to the best of your knowledge. Current Weight: Height: Are you happy with your weight? Y/N Please list any current and/or previous injuries. Personal Training Par-Q (Physical Readiness Questionnaire 1. Has your doctor said that you have a heart condition and that you should only do physical activity recommended by your doctor? Y / N 2. Do you feel pain in your chest when you do physical activity? Y / N 3. In the past month, have you had chest pain when you were not doing physical activity? Y / N 4. Do you lose your balance because of dizziness, or do you ever lose consciousness? Y / N 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition? 7. Did your doctor tell you not to workout because of any serious orthopedic problems that would prevent you from exercising? If yes, please explain. 8. If you have answered yes to any of these questions, do you have clearance from your physician to exercise and to do a resistance training program? Y / N

4 Page 4 MEDICAL HISTORY Present & Past History Have you had or do you presently have any of the following conditions? (Check any that apply.) Rheumatic fever Recent operation Edema (swelling of ankles) High blood pressure Injury to the back or knees Low blood pressure Seizures Lung disease Heart attack Fainting or dizziness Diabetes Angina High cholesterol Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night) Shortness of breath at rest or with mild exertion Chest pain Palpitations or tachycardia (unusually strong or rapid heartbeat) Intermittent claudication (calf cramping) Pain, discomfort in the chest, neck, jaw, arms, or other areas Known heart murmur Unusual fatigue or shortness of breath with usual activities Temporary loss of visual acuity or speech, or short- term numbness or weakness in one side, arm, or leg Other, Please list: Do you smoke? Y / N If yes how many packs do you smoke a day? If no, are you a former smoker? How long ago did you quit smoking? Please list any current and/or previous injuries: Are you currently on any heart or blood pressure medication: Y / N If yes, please list medications:

5 Page 5 GOAL SETTING WORKSHEET If you don t know where you are going, how are you ever going to get there!? Take a moment to thing about your goals. You ve made a commitment to your health and fitness, why? What is it that you would like to see as a return on your investment? Where do you want to be, with regards to your well-being, six months from now? A year from now? Ten years from now? Take a moment to write down a few of these goals. Doing so will give your workouts a sense of purpose, and will give you the direction you need to ensure that this vehicle called exercise will take you down the right roads. Short-term goals: Long-term goals: To increase my activity, exercise and fitness levels, I will take the following steps: Weight and Eating Habits: To eat healthier and achieve a more reasonable weight, I will take the following steps: 1. : 2. : 3. : 4. : 5. : Additional Goals (Sleep, smoking, alcohol, etc.): I hereby commit myself to achieving the above goals to the best of my ability, and I agree to seek help in reaching these goals when I need it, whatever the road blocks may be. I hereby agree to help the above client achieve his/her fitness goals to the best of my ability. I agree to seek out other resources when needed, and to do what I can to help this individual stay on track. Trainer s Signature

6 Page 6 RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT In consideration of being permitted to utilize the facilities, services and programs of the Pittsfield Family YMCA for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with YMCA, the undersigned for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect, and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation. In further consideration of being permitted to enter the YMCA for any purpose including, but not limited to observation or use of the facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned hereby agrees to the following: 1. The undersigned hereby releases, waives, discharges, and covenants not to sue the YMCA, its directors, officers, employees, agents and personal trainers (hereinafter referred to as releasees ) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any programs affiliated with the YMCA. 2. The undersigned hereby agrees to indemnify and save and hold harmless the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise. 3. The undersigned hereby assumes full responsibility for and risk of bodily injury, death or property damage due to negligence of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with YMCA. The undersigned further expressly agrees that the forgoing release, waiver and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the State of Massachusetts and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The undersigned has read and voluntarily signs the release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. PHOTO RELEASE: The undersigned also agrees that the Y may photo or videotape me and use it for promotion or in the media. I HAVE READ AND UNDERSTAND THIS RELEASE. (PLEASE PRINT CLEARLY.) PITTSFIELD FAMILY YMCA 292 North Street, Pittsfield MA P F