PERSONAL TRAINER Request Form PLEASE COMPLETE ALL PAGES AND RETURN WITH YOUR REQUEST. This gives your Personal Trainer important information needed before your appointment.
Name _______________________________________________________________ Date____________________________ Age ________ Address __________________________________________________________________________________ Phone number (home) ____________________________ Phone number (other)__________________________________ When is the best time to contact you? _____________________________________________________________________ Do you have a trainer preference? Male _____ Female _____ OR Name of trainer you prefer (if any) ________________________________________________________________________ You can find Bios for our trainers at http://cityofgolden.net/Personaltraining What days of the week and times are best for your session? ___________________________________________________ How many sessions are you interested in purchasing?* ________________________________________________________
*Please see back page for details. Which of the following goals do you have? ____ Gain weight/muscle ____ Increase energy ____ Reduce Stress ____ Improve Cardiovascular fitness ____ Rehabilitate injury ____ Improve flexibility ____ Lose weight/inches ____ Prevent injury ____ Improve muscle tone/shape ____ Improve strength ____ Sports training ____ Other (explain) What sport? ____________ How did you hear about us? ______________________________________________________________________________
CANCELLATION POLICY: We require 24 hour notice for cancellations of your scheduled appointment. If you are unable to give 24 hours notice, you will be charged for the session. I have read and understand the cancellation policy. (Participants under 18 require a Parents signature please) Signed: _________________________________ Relationship (if under 18) ___________________________Date________
Payment is due when this form is turned into the front desk
Staff use only: CSR initial _____ Date _______________ Type of Package: ________________________________ Referred to: _____________________________________ Amount Paid: Resident _______ Non-Resident _______ Date: ___________________________________________ By: _____________________________________________
PAR Q Physical Activity Readiness Questionnaire Name
Date
DOB
Age
Home Phone
Work Phone
Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However, some individuals should check with a physician before they become more physically active. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly:
Yes
No
1) Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity?
Yes
No
2) When you perform physical activity, do you feel pain in your chest?
Yes
No
3) When you were not engaging in physical activity, have you experienced chest pain in the past month?
Yes
No
4) Do you ever faint or get dizzy and lose your balance?
Yes
No
5) Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity?
Yes
No
6) Do you have high blood pressure or a heart condition in which a physician is currently prescribing a medication?
Yes
No
7) Are you pregnant?
Yes
No
8) Do you have insulin dependent diabetes?
Yes
No
9) Are you 69 years of age or older and not used to being very active?
Yes
No
10) Do you know of any other reason you should not exercise or increase your physical activity?
If you answered yes to one or more of the above questions, you will need to get a Physical Activity Release from your doctor before you become more physically active. If you honestly answered no to all questions you can be reasonably certain you can safely increase your level of physical activity gradually. If your health changes so you then answer yes to any of the above questions, seek guidance from a physician. Participant signature
Date
WELLNESS HISTORY & INFORMATION FORM Name _________________________________________________________________________________________________ Email address (not required)______________________________________________________________________________ Age ________ Gender _________ Height _________________ Weight ______________ Birthday ___________________ Please list an emergency contact (required) and your Physician’s name and Phone Number. Contact __________________________ Relation _______________________ Phone # ______________________________ Physician’s Name _________________________________ Phone # _____________________________________________ Are you presently exercising? __________________ how many hours a week? ____________________ Briefly describe your exercise program:
List any injuries or physical conditions that might affect your ability to exercise:
Please list any illnesses, hospitalization, or surgical procedures that you have had within the last two years: List any medications you are presently taking, dose, and reason:
Please list any over-the-counter medications and dietary supplements you are currently taking:
Do you have high blood pressure? ____________ High Cholesterol? ____________________ Do you smoke? ___________________________ if yes, how much? _____________________________________________ Please list any sports you currently participate in:___________________________________________________________
WAIVER FOR PARTICIPATION: I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction. I, the undersigned, parent or guardian (if under 18), do hereby agree to allow the individual(s) named herein to participate in the aforementioned activity(s). Further, my family and I agree to indemnify and hold Golden Parks and Recreation department harmless from and against any and all liability for any injury, including death, which may be suffered by the aforementioned individual(s), arising out of or in any way connected with his/her participating in this/these activity(s). I am signing this waiver freely and voluntarily.
Signature: __________________________________________________ Date _______________________________
LIFESTYLE INFORMATION FORM Name __________________________________________________ Date _________________________________________ Physical Activity In the past year, how often have you been engaged in physical activity? Regularly (3 to 4 times a week) Semi-regularly (1 to 2 times a week) Sporadic (1 to 2 times a month) None
What types of physical activity do you consider “fun”? What are your personal barriers to exercise (ie, your reasons for not exercising)? What physical activity have you been successful with in the past (liked and participated in regularly)? How do you think your weight affects your daily activities? Support Do you feel any family, friends or co-workers have negative feelings (ie disapproval, resentment) towards your efforts at physical activity? Is your significant other or a close friend involved in any regular physical activity? Occupation/Leisure What is your present occupation? Does your occupation require much activity (ie walking, getting up and down, carrying things)? What are your usual leisure activities? Stressors What types of things make you feel stressed? How do you normally deal with your stress? Dietary Patterns How many meals and/or snacks do you have per day? What would you estimate your caloric intake to be per day? Do you feel you eat healthy “most of the time” ? How much water would you estimate you drink per day? Expectations Specifically describe what you would like to accomplish through your fitness program during the next: 1 month: 4 months: 1 year:
Keep your training and fitness regime up-to-date and fun! Book a session with a Personal Trainer or learn to use the weight room correctly. Whatever your plans are, here are your options: Personal Training Sign up for a Personal Trainer and receive a personal fitness routine created just for you! Please wear shorts and a short sleeved shirt to your appointment, eat and drink as usual. Age 14 years and older. One-Hour Session $42 Resident 3 Sessions $116 Resident 6 Sessions $222 Resident 12 Sessions $419 Resident 24 Sessions $792 Resident 36 Sessions $1116 Resident
$47 Non-resident $131 Non-resident $262 Non-resident $479 Non-resident $882 Non-resident $1,236 Non-resident
Train With A Friend Train with one other person in a semi-private session! Each session is one (1) hour in duration. One Hour Session $27 Resident $32 Non-resident – per person 3 (One Hour) Sessions $75 Resident $90 Non-resident – per person 6 (One Hour) Sessions $138 Resident $168 Non-resident – per person 12 (One Hour) Sessions $252 Resident $312 Non-resident – per person 24 (One Hour) Sessions $456 Resident $546 Non-resident – per person 36 (One Hour) Sessions $612 Resident $732 Non-resident – per person
Group Personal Training Groups of 3 to 5 people are welcome to session is one (1) hour in duration. Price One Hour Session $17 Resident 3 (One Hour) Sessions $45 Resident 6 (One Hour) Sessions $78 Resident 12 (One Hour) Sessions $144 Resident
participate; you must organize your own group. Each is per person. $22 Non-resident – per person $50 Non-resident – per person $83 Non-resident – per person $149 Non-resident – per person
Body Composition Testing Body Composition (lean tissue vs fat tissue) is essential to monitor your weight loss progress. A certified Personal Trainer will use calipers on select areas of your body to find your lean to fat ratio. Each Body Composition session takes approximately 30 minutes, and includes a private discussion with your certified Personal Trainer afterwards to discuss your goals and what direction you can go to achieve them. Age: 18 years and older. $10 Resident $15 Non-resident
Weight Room Orientation Learn how to correctly set yourself up on the weight machines and how to use them. Led by our professional Personal Trainers, they also will be able to offer general guidelines on fitness and weight bearing activities. This class is not a Personal Training, so the trainers will not be able to answer questions specific to your workout. Please call 303-3848159 to set up a time and day for the orientation.
Youth/Teen Weight Room Training Certification Anyone under 16 cannot use the weight room without a weight room certification. To receive the certification, teens 14-16 need to take a teen weight room orientation. Please call 303-384-8159 to set up a time and day for the orientation.
Frequently Asked Questions? When Will My Trainer Call?
Please allow at least 3 working days after you turn in your request for us to contact you.
What if I Have to Cancel My Appointment? If you need to cancel, please give your Personal Trainer a courtesy call 24 hours in advance, at the number they give you to contact them. If you do not have their number, please call 303-384-8100. Thank you for your consideration.
Physical Activity Release Form Golden Community Center
___________________________________________ has my approval to participate in a (Participants Name)
progressive exercise program. I understand the physical and physiological stressors of the program and see no reason why the above named person should not participate.
Physician Name (please print)
Physician Address
Phone
Fax
__________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ____________________________ Restrictions (HR, intensity, ROM)?
Physician Signature
Date
Please Fax to: Wellness Coordinator Golden Community Center 303-384-8104
