Personal Training Request Form
Please fill out completely to be considered for a private online training program with Michelle Melendez.
Name
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First Name
Last Name
E-mail
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Phone Number
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-
Area Code
Phone Number
Mailing Address:
Days you'd like to train.
Monday
Tuesday
Wednesday
Thursday
Friday
Sunday
Time range you're available to train. (All sessions are 60-minutes long.)
Briefly describe your health and fitness goals for the next 3-months:
What is your biggest challenge when getting fit?
Have you ever worked with a personal trainer before?
Yes
No
On a scale of 1-5, 5 being 100% committed, how committed are you in reaching your goals?
5: VERY Committed! I'm serious and Ready To GO!
4: Feeling committed and unsure
3: Starting to feel committed
2: kind of committed
1: Not committed at all
Physical Active Readiness Health Questionairre:
Has your doctor ever said you have heart trouble?
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Yes
No
Do you frequently have pains in your heart or chest?
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Yes
No
Do you often feel faint or have spells of severe dizziness?
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Yes
No
Has your doctor ever said your blood pressure is too high?
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Yes
No
Has your doctor ever told you that you have a bone or joint problem such as arthritis that can be aggravated by exercise, or might be made worse?
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Yes
No
Are you over the age of 55 and not accustomed to vigorous exercise?
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Yes
No
Is there a good physical reason not mentioned here why you should not follow an activity program if you want to?
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Yes
No
If you've answered yes to any of the above, it is HIGHLY recommended you get approval from your doctor BEFORE you begin exercise. You take 100% responsibility for your health.
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I understand and I will check with doc if needed
I do not understand
Is there anything else you want your trainer to know? (Please include injuries or health concerns.)
What training program works you for you?
Single $120
Double $140
PAYMENT INFO: Your first session is complimentary. After that payments are taken monthly from a credit card authorized by you. You are sent an email at the end of each month with the invoice showing your training sessions for the next month and may change as needed. (Sessions may be canceled or rescheduled within 24-hours.)
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Yes
No
30-DAY NOTICE OF CANCELATION: Within your first 30-days you may cancel ANYTIME. After that your program renews each month and you may cancel with a 30-day notice. This helps us keep a regular budget. Thank you.
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Yes
No
By typing your name here you take FULL responsibility for your health and safety by participating in a private training program lead by Santiago Quintero, and Michelle Melendez. You release them of ANY and ALL liability should you be injured or worse.
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