Instructional Program Questionnaire

Instructional Program Questionnaire
Client Information
Last Name:*
First Name:*
Date:*

MonthDayYear
Date
Address:*
City:*
State:*
Zip:*
Date of Birth:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail (Enter your OSU email if you have one):*
example@example.com
CWID:*
UndergraduateGraduateFaculty/StaffOther
CashCheckBursarCredit Card
Emergency Contact Information
Full Name:*
Relationship:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What Program are you interested in joining?*
Fitness History and Goals: (Please be as detailed as possible)
1. Please describe your current and/or previous exercise experience:*
2. Do you have a hernia/other condition that could be aggravated by lifting weights?*
3.Have you ever begun an exercise program but not followed through? If so, what were contributing factors to not finishing the program?*
Weight lossCardiovascular EnduranceMuscular strengthFlexibilityMuscular EnduranceBalance/StabilityOther
5. Please specify any forms of exercise you know you cannot do.*
6. Do you smoke or have you quit smoking in the last 3 months?*
7. Are you currently pregnant or less than 3 months postpartum?*
Physical Activity Readiness Questionnaire (PAR-Q+, OSHF, 2017)
YesNo
YesNo
YesNo
YesNo
If yes, please list condition(s) below:
YesNo
If yes, please list medication(s) and condition(s) below:
YesNo
If yes, please list condition(s) below:
YesNo
If you answered “no” to all of the previous questions, you are cleared for physical activity without medical clearance. You may skip to the end, read and sign the agreement.

If you answered “yes” to ANY of the above questions, you will need to obtain medical clearance from your physician before participating in a personal training program.
If you answered “yes” to ANY of the above question, please read the 8 questions below carefully and answer each one honestly.
YesNo
If yes, please specify condition(s):
YesNo
If yes, please specify below:
YesNo
YesNo
If yes, please specify condition(s):
YesNo
If yes, please specify condition(s):
YesNo
If yes, please specify condition(s):
YesNo
YesNo
Please list any other medical conditions you may have that are not included in this form.
Missed Classes: I understand that the classes/sessions are pre-determined and that if I miss a class for any reason I forfeit that class.

Refund Policy: F45, Group Fitness, and Cowboy Strong CrossFit semester memberships are NON-REFUNDABLE.

Release and Indemnity Agreement: I hereby release the Board of Regents at Oklahoma State University and all its employees from all claims on account of injury which may be sustained while participating in this program, and I agree to indemnify the Board of Regents of Oklahoma State University and its employees for any claim which may hereafter be presented as a result of such injuries.
Print Name:*
Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Instructional Program Questionnaire

Client Information

Emergency Contact Information