Personal Trainer Request Form Logo

  • Personal Trainer Request Form

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  • Local/Campus Address

  • Emergency Contact Information

  • Availability

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  • Health/Fitness Pre-Participation Screening Questionnaire

    All of the following information is private and confidential and is for the safety of your participation in this program.

  • Symptoms

  • * IMPORTANT:


    If you marked "Yes" on more than one of the statements above, consult your physician or other appropriate health care provider before engaging in exercise.

    You may need to use a facility with a qualified medical staff, which is not available through Campus Recreation. Your physician/health care provider may FAX your release to exercise to Campus Recreation at (309) 298-3224.

    Please sign below to acknowledge that you understand.

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  • Cardiovascular Risk Factors

  • Questionnaire is a modified version of ACSM's Guidelines For Exercise Testing and Prescription.

    * Your responses to the Cardiovascular Risk Factors section of the Other Health Issues sections of the Health/Fitness Pre-Participation Screening Questionnaire may require you to consult your physician or other appropriate health care provider before engaging in exercise.

    Please sign below to acknowledge that you understand.

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  • Client Goals

    Indicate how important to you accomplishing each of the following goals is:
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  • PERSONAL TRAINING WAIVER INFORMATION

    Please read this form carefully and be aware that by signing this form you will be waiving and releasing all claims for injuries you might sustain while participating in the personal training program.

  • Western Illinois University is committed to conducting its personal training sessions in the safest manner possible and holds the safety of participants in the highest possible regard. Western Illinois University continually strives to reduce such risks and insists that all participants in the personal training program follow safety rules and instructions, which have been designed to ensure the participant's safety.

    Western Illinois University does not carry medical accident insurance for injuries sustained in its personal training programs. The cost of such would make program fees prohibitive. Therefore, each person registering themselves for the personal training sessions should review their own health insurance for coverage. It must be noted that the absence of health insurance coverage does not make Western Illinois University automatically responsible for the payment of medical expenses.

    WAIVER AND RELEASE OF ALL CLAIMS

    As a client in the personal training program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, death, damage or losses, which I may sustain as a result of participating in any and all personal training activities.

    I do hereby fully release and discharge Western Illinois University, its officers, agents, servants, employees, and the Board of Trustees of Western Illinois University from any and all claims from injuries, death, damages or loss, which I may have or which I may accrue through training with a personal trainer.

    If I have known health concerns prior to starting a strength training, cardiovascular, or flexibility program I agree to seek the advice of a physician or medical professional before beginning the personal training program. Any health or fitness information that is not disclosed prior to the first personal training session is done at the client's own risk and therefore releases Western Illinois University, its officers, agents, servants, employees, and the Board of Trustees from any injuries, death, damages, or losses that may occur.

    Any changes including but not limited to: repetitions, sets, frequency, intensity or duration that are made to my strength training, cardiovascular, or flexibility program without consulting a personal training professional first are done at my own risk and I hereby agree to release Western Illinois University, its officers, agents, servants, employees, and the Board of Trustees from any injuries, death, damages or loss which may occur through these changes.

    PERMISSION TO SECURE TREATMENT

    In the event of an emergency, I authorize Western Illinois University officials and the Board of Trustees of Western Illinois University to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my immediate care and I agree that I will be responsible for payment of any and all medical services rendered.

    I have read and fully understand the above Personal Training Program details, the Waiver/Release of All Claims, and the Permission to Secure Treatment.

    Please sign below to agree to the liability waiver.

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  • Personal Trainer Info

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