The University of Texas at Dallas Department of Recreational Sports Personal Training Registration Form
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1 The University of Texas at Dallas Department of Recreational Sports Personal Training Registration Form Directions: Please, fill out as much information as possible. If you are unsure, leave that question blank. Name: Phone Number: Address: Time Preference: Date of Birth: Trainer Preference (M/F): Who Referred You: Personal Training Sessions Member Non-member Single Session $30 $35 Single Session Buddy System $20 per person $25 per person Basic Package (4 sessions) $110 $130 Basic Package Buddy System $72 per person $104 per person Premium Package (8 sessions) $188 $228 Premium Package Buddy System Deluxe Package (12 sessions) Deluxe Package Buddy System $136 per person $269 $180 per person $176 per person $329 $240 per person All payments must be received prior to the scheduling of your personal training session(s). Please note that the following policy will be enforced for all personal training sessions: There will be a 24-hour cancellation policy on all sessions. If the client does not cancel within 24 hours the session will be void and no refund will be given. No purchases for personal training can be made without the presence of your trainer. No refunds on purchased sessions will be given unless due to medical reasons. Registration packet/waivers must be filled out prior to your first session. Participation in all activities in the UTD Activity Center, sponsored by the Department of Recreational Sports, is voluntary on behalf of all participants. Participants acknowledge and agree that the University of Texas at Dallas does not provide insurance for any of its activities and shall not be liable for any injuries that occur at this location or any of it programs. Participants Signature Date 1
2 Personal Medical History Past Operations: Hospitalizations: Disabilities/limitations: Diseases: Are you currently under a physician s care? (Circle) If yes, please explain:_ Length of time since last check-up: Physician Name: Phone Number: Please list any medications that you are currently taking and the reason why it was prescribed: Are any of these prescriptions classified as a Beta Blocker? (Circle) Are you allergic to any medications? (Circle) If yes, please specify: In case of emergency, please provide contact information below: Name: Phone Number: (Home) (Work): Relationship to contact: Please indicate (circle) below if you have any history of the following ailments: During the past 12 month, has your weight fluctuated more than a few pounds? Heart Disease/Surgery If yes, please explain: Heart Murmur Enlarged Heart Chest Pain with exertion Stroke If yes, please explain: Peripheral Vascular Disease Physical exam in past 5 years Epilepsy 2
3 Varicose Veins Blood Clots High Blood Pressure Systolic: Diastolic: Elevated Cholesterol Level: Elevated triglycerides: Level: Recent Surgery If yes, please explain: Resting Heart Rate: EKG: Never Taken: Normal Abnormal _ If abnormal, please explain: Stress Test Never Taken: Normal Abnormal _ If abnormal, please explain: Light-Headed Fainting Shortness of Breath Asthma Exercise Induced Asthma Rheumatic fever Hernia Anemia Diagnosed Hypoglycemia Diabetes Obesity Anorexia Bulimia Severe Headaches Insomnia Chronic Morning Cough Kidney failure Kidney removal Kidney stones Kidney Dialysis Gout Gallbladder removal Gallbladder Disease/stones Colitis Arthritis If yes, please explain area affected: Sickle Cell trait Back Pain/Sciatia Shoulder Injury or Pain 3
4 Calcium Deposits Fibromyalgia Swelling in Feet or Ankles Ankle/foot injury of Pain Knee Injury or pain Nerve Damage Numbness/Tingling in Limbs If yes, please explain where you are affected: Head/Neck Injury or Pain Bone Fracture If yes, where: Hip Injury/Pain Tennis Elbow Shin Splints Achilles Pain Fatigue Cancer In yes, please explain: Smoker If yes, how long/number per day/or time since quitting: Family Medical History Please list the family members affected, the age of onset, type and the action taken for the following ailments: Heart Disease High Blood Pressure Elevated Cholesterol Diabetes Cancer Stroke Obesity Please provide any additional comments below: 4
5 Personal Fitness Evaluation **FOR PERSONAL TRAINER USE ONLY. TO BE FILLED OUT AT TIME OF INITIAL CONSULTATION. Please fill out these questions thoroughly and completely. If you have any questions, please feel free to ask your trainer for assistance. 1. Do you have any negative feelings toward or have you had any bad experience with physical activity programs? 2. Do you have any negative feelings toward or have you had any bad experiences with fitness testing and evaluation? 3. Rate yourself on a scale 1 to 5, with 1 indicating the lowest value and 5 the highest value. Circle the number most applicable to you. Characterize your present athletic ability: Characterize your present cardiovascular capacity Characterize your present muscular capacity: Characterize your present level of flexibility: Characterize your stress level at work or school Are you currently involved in regular exercise? (Circle) If yes, what type of exercise? 5. What types of activities interest you? 6. Do you enjoy participating in activities alone, or do you prefer being part of a group? 7. What barriers do you think have prevented you in the past from beginning or adhering to an exercise program? 5
6 8. Rank goals 1 to 10, where 1 is the most important to you: Improve cardiovascular fitness Reduce body fat level Reshape or tone body Improve flexibility Lose weight Gain Weight Enjoyment Increase Strength Increase energy level Other (please explain) 9. Describe your eating habits. What types of foods do you eat? How is your control? Body Composition (Trainer only) Date Trainers Initials Height Weight Body Fat Percentage Body Mass Index Body Measurements Start Goal 30 days 60 Days 90 days Right/Left Arm Right/Left Leg Waist Hips Chest Calipers Start Goal 30 days 60 Days 90 days Biceps Triceps Iliac Supra Scapula Cardio, Strength, Flexibility Assessment Date Trainers Initials Start Goal 30 days 60 Days 90 days Blood Pressure Resting Pulse Max HR= 220 yr age 6
7 Functional Movement Screen NAME: ADDRESS: CITY, STATE, ZIP: PHONE: HEIGHT: WEIGHT: AGE: DATE; TEST SHOULDER MOBILITY RAW SCORE L: R: 60 DAY/ FINAL SCORE COMMENTS DEEP SQUAT STAR BALANCE TEST INLINE LUNGE L: R: L: R: CORE TEST ACTIVE STRAIGHT- LEG RAISE L: R: TRUNK STABILITY PUSHUP ROTARY STABILITY L: R: Summary of Fitness Assessment 1.) Cardiovascular Status: 2.) Weight Training Experience: 3.) Muscular Endurance: 4.) Overall Muscular Strength: 5.) Flexibility: 6.) Overall Posture: PERSONAL TRAINER S SIGNATURE: DATE: 7
8 Fitness Evaluation and Program Participation I have volunteered to participate in a program of progressive physical exercise. I waive any possibility of personal damage which may be blamed upon such a program in the future and accept the responsibility for accepting such exercise and assistance. The possibility of certain unusual changes during exercise does exist, including abnormal blood pressure, fainting, disorders of heat beat, and very rare instances of heart attacks. Every effort will be made to minimize such changes by preliminary examination and observation during situations which may arise. I herby acknowledge and accept these which would preclude an exercise program. Participant s signature: Date: An examination by a physician should be obtained by all participants prior to involvement in an exercise program. If a participant refuses to obtain a physician s consent, he/she must sign the following statement: I, _, have been informed of the need for a physician s approval for participation in a progressive exercise and fitness program. I fully understand the strenuous nature of the program and accept complete responsibility for my health and understand that no responsibility is assumed by the leaders of the program or sponsoring agency. Participant s signature: Date: has medical approval to participate in an exercise and fitness program which will include progressively increasing amounts of general conditioning exercises. I certify that the person whose name appears above is free from infectious disease and that there appears to be no reason why such an exercise program should not be undertaken. Physician s signature: Date: Participation in all activities in the UTD Activity Center, sponsored by the Department of Recreational Sports, is voluntary on behalf of all participants. Participants acknowledge and agree that the University of Texas at Dallas does not provide insurance for any of its activities and shall not be liable for any injuries that occur at this location or any of it programs. 8
9 Informed Consent for Exercising and Fitness Training The University of Texas at Dallas Activity Center I agree to voluntarily participate in a Personal Training program in the attempt to improve cardiovascular and physical fitness. I understand that the purpose of this program is to accomplish goals set by myself with a specific program based on needs, interests, and recommendations by certified fitness instructor. Furthermore, I understand that the recommendation made are no more than recommendations, and will or have consulted a doctor concerning such recommendations before attempting any training program. The reaction of the cardio-respiratory and skeletal/muscle systems cannot be predicted with complete accuracy. All exercise programs will include a warm up, strength training and/or cardio-respiratory conditioning at a target heart rate or equivalent perceived exertions, and a proper cool down period. I understand that I am responsible for monitoring my own condition throughout the exercise program and will cease any activity and inform the trainer of any unusual symptoms. If requested by certified personal trainer I may be required to bring a physician s approval and/or recommendations before starting any program. I certify that I am in good health and if at any time these conditions change I will notify the personal training staff. It is expressly agreed that all use of the UTD fitness equipment and/or facilities shall be undertaken by a participant at his/her own risk, and any corporate entity and/or the UTD fitness facility shall not be liable for any injuries or any damage to any participant or the property of any participant whatsoever, including, without any limitations, those damages resulting in acts of passive or active negligence on the part of and corporate entity and/or the UTD fitness facility. The participant, for himself/herself and on behalf of his/her executors, administrators, heirs, assigns, and successors, does hereby expressly forever release and discharge any corporate entity, the State of Texas, The University of Texas System, the University of Texas at Dallas, the UTD fitness facility, its officers, employees, and successors from al such claim, demands, injuries, damages, actions, of causes of action. Any corporate entity and/or the UTD fitness facility shall not be responsible or liable to participant for articles damaged, lost or stolen in or about any corporate entity and/or the UTD fitness facility or from lockers, or for loss or damages to any property including but not limited to automobile and contents thereof. In signing the consent from, I affirm that I have read this form in its entirety and that I understand the nature of the exercise program. I also affirm that my questions regarding the exercise program have been answered to my satisfaction. Participant s signature Date 9
10 The University of Texas at Dallas Personal Training Agreement Name: Phone: (H) (C) Personal Trainer: Date Time Member's Signature Trainer's Signature Date Time Member's Signature Trainer's Signature Terms of Agreement 1. Members and trainer must sign for each session upon completion thereof for confirmation of service 2. Cancellation require a 24-hour notice, if notice is not given member will be charged for missed session. 3. Refunds are given for medical reason only 4. Problems or concerns should be addressed to Personal Trainer Fitness Supervisor Member Signature: Trainer s Signature: Date: _ Total Price$ Date: _ B.S. Name: Total Paid $ Date: _ B.S. Name: Total Paid $ Date: _ B.S. Name: Total Paid $ Date: _ B.S. Name: 10
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