Personal Training Registration

Personal Training Registration

General Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
R#/Membership# (Numbers only)*
Age*
Date of Birth*

MonthDayYear
Date
Is there anything you would like us to know about your health/lifestyle/general?
Package Information and Selection
Package Selection (expire after 365 days)

5 Sessions $15010 Sessions $29015 Sessions $41020 Sessions $540

Personal Training Registration - New Client

PAR-Q: Page 1
Has your Doctor ever said that you have a heart condition or high blood pressure?*

Yes - High Blood PressureYes - Heart Condition*(See Below)*No
*Heart conditions include *
- Heart attack
- Heart surgery, catheterization, or coronary angioplasty
- Have a pacemaker, implantable cardiac defibrillator, or rhythmic disturbance
- Heart valve disease
- Have had heart failure
- Have had heart transplant
- Have congenital heart disease
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*

YesNo
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? (Please answer NO if your dizziness was associated with over-breathing, including during vigorous exercise)*

YesNo
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

YesNo
List any conditions here.
Are you currently taking prescribed medications for a chronic medical condition?**

YesNo
List medications here.
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? (Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.*

YesNo
List conditions here.
Has your doctor ever said that you should only do medically supervised physical activity?*

YesNo
Please type your full-name below to show you attest that you were honest when answering all previous questions.
Personal Training Registration - New Client

Availability and Preferences
Did someone refer you to our program?

YesNo
Who was it?
Do you have a personal trainer you would prefer to work with?
Do you prefer a female or male trainer?*

Please mark ideal timing windows in which you would like to train.*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Early Morning (6am - 8 am)
Mid-Morning (8am-10am)
Late Morning (10am-12pm)
Early Afternoon (12:00pm-2:00pm)
Mid Afternoon(2:00pm-4:00pm)
Late Afternoon/Early Evening (4:00pm-7:00pm)
Beyond 7:00pm

Personal Training Registration - New Client

Package Selection, Terms and Conditions, and Waiver
Will you be purchasing virtual, or face to face personal training sessions?*

Face to faceVirtual
Which type of assessment would you prefer?

In person (more in depth and accurate analysis) +$17Virtual assessment (Movement assessments and goal setting only) - Included with purchase of at least 3 virtual sessions.
Type initials to show understanding: The expiration policy requires that sessions be used within the semester the are purchased (3-16 sessions) or within one year of purchase date (24-32 sessions)*
Type initials to show understanding: Refunds on personal training packages and sessions will not be issued at any time for any reason including but not limited to relocation, illness, and unused sessions. In case of major illness, providing a doctors note will warrant a refund.*
Client/Personal Trainer Agreement: This agreement ensures that the role of the trainer to client and client to trainer is clearly appreciated and understood. This agreement must be signed prior to beginning the training sessions. To keep this program running smoothly, we would like to outline the following client responsibilities: The training fee must be paid when filling out the Personal Training Registration Packet. This entitles the client to one hour long (60 minute) training sessions. Complete all forms in the packet provided and turn them into the Fitness/Wellness Center. Failure to do so may result in delayed initial consultation. These completed forms will be used in establishing your baseline and are entirely confidential. Be on time for meetings with your Personal Trainer. Sessions last only 60 minutes. If the client is late, the Personal Trainer must wait 15 minutes before leaving. If the client shows up within the 15 minute time block, continue the session as planned, ending 60 minutes after the planned start time.(i.e. if client shows up at 4:12pm and the session is scheduled for 4pm, the session will still end at 5pm). If a session needs to be canceled for any reason other than an emergency, a 24-hour notice must be given to the trainer. Failure to do so will result in the client forfeiting the session and no payment reimbursement will be granted. You must abide by all Student Recreation & Aquatic Center rules and regulations. No roll-over sessions or refunds will be granted, except for medical reasons, which must be endorsed by your physician. It is recommended that you bring a towel and water bottle (NO GLASS BOTTLES) to every session. If you have any questions feel free to contact the Graduate Assistant of Strength and Conditioning at (806) 834-0407.TRAINER RESPONSIBILITIES: A personal trainer provides Tech students, staff, faculty, alumni, and dependents with the motivation, education, guidance, and individual instruction required to achieve their personal fitness goals. The trainer will design a safe, effective exercise program on an individual basis that reflects the client’s objectives, fitness level, and experience. If the trainer is late for a session, that time is owed to the client at no additional charge. Once you have purchased a personal training package, your trainer will contact you within the next 2 business days by email. The trainer will maintain an open line of communication throughout the course of service. If there is a problem with a trainer’s customer service, the client should contact the Graduate Assistant of Strength and Conditioning at (806) 834-0407. By signing this agreement you indicate that YOU understand YOUR roles and will do your part to ensure the best results for the goals set.*

Clear
I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in the Recreational Sport’s Personal Training Program may cause injury, am voluntarily choosing to participate in the program. There are always certain risks associated with any physical activity. I understand these risks and declare myself physically sound and capable to participate in program offered through Texas Tech University Recreational Sports Office. The Personal Training Program is a program designed to guide me, safely and effectively, through an appropriate individualized fitness/exercise regime based on my initial fitness assessment and goal assessment. Following the completion of a health history form and possibly a doctor’s note and an initial consultation, I will be given an individual exercise program that focuses on increasing fitness to prepare me for normal activities of daily living. I realize that I have the option to discontinue any activity upon my own discretion. I also realize that all information obtained about myself through this program will be kept in strict confidence within the Personal Training Program. In making this activity available for your participation, Texas Tech University Recreational Sports Office assumes no responsibility for injury. The responsibility is assumed entirely by the participant. Participants should have adequate personal insurance coverage. “Having such knowledge, I do hereby release Texas Tech University, the State of Texas, the Board of Regents, employees and student employees of all liability related to injuries or accidents to myself which may occur as a result of participation in the Personal Training Program. I hereby assume all risks connected there with and consent to participate in the Personal Training Program.”*

Clear
Should be Empty:

Personal Training Registration

Package Information and Selection

Personal Training Registration - New Client

Personal Training Registration - New Client

Personal Training Registration - New Client