Personal Training Request Form
Name: / Age: Banner ID: @Gender:
/ STATUS:
Phone: / Email:
Address:
City: / Zip:
Preferred Training Package: (please circle)
60 Minute Sessions 30 Minute Sessions
2 sessions / $50 / 4 sessions / $804 sessions / $90 / 8 sessions / $140
8 sessions / $160 / 16 sessions / $240
16 sessions / $300
24 sessions / $410
Share-A-Trainer* Small Group Training* (4 – 6 people)
2 sessions / $80 ($40) / 4 sessions / $210 ($35)4 sessions / $110 ($55) / 8 sessions / $336 ($56)
8 sessions / $175 ($87.50) / 16 sessions / $630 ($105)
16 sessions / $320 ($160) / 24 sessions / $780 ($130)
24 sessions / $425 ($212.50)
*Price shown is the total cost. Per person is noted in (parentheses). For Small Group Training, the price in (parentheses) notes price per person if there were 6 people registering together.
Training With (if purchasing Share-A-Trainer or Small Group Training):Referred By:
Personal Trainer Preference (if applicable):
Male / Female Name:
Preferred day(s) and time(s) of training sessions:
PLEASE NOTE: This form must be turned in upon payment for sessions. This will ensure you that you are contacted by your trainer to schedule your first session. You will be contacted by our fitness staff within 3-4 business days for more information. To receive optimum benefits from the personal training program, it is recommended that a minimum of one session be used per week. Please see the last page in this packet for refund information.
______
Staff Use Only:Date Purchased: ______Sold by: ______Amount Paid: ______
Method of payment:______
Signature Date
Campus Recreation
Physical Activity Readiness Questionnaire (PAR-Q)
Please answer Yes or NoHas your doctor ever said you have a heart condition and you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were NOT doing physical activity?
Do you ever lose consciousness or do you lose your balance because of dizziness?
Do you have a bone or joint problem (for example: back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition?
Are you pregnant?
Do you know of any other reason you should not exercise or increase your physical activity? If yes, please list below.
If you answered YES to any of the above questions please explain below:
______
If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before engaging in a fitness assessment or physical activity. A medical clearance may be needed for individuals who have a high risk of medical complications from exercise. If your health changes so you then answer YES to any of the above questions, seek guidance from a physician.
I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.
Print Name: ______
Date: ______
Confidentiality Notice
This document contains confidential information intended only for the use of the Campus Recreation Center and the individual member.
Privacy Statement
You are entitled to be informed about the information UTSA collects about you. Under Section 552.021 and 552.023 of the Texas Government code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government code, you are entitled to have UTSA correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in the University of Texas System Business Procedures Memorandum 32. The information that UTSA collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
Exercise History and Goals
Name: Date:
Height: ______Weight: ______
1. In the past year, how often have you been engaging in physical activity?
____Regularly (3-4+ times/week)
___Semi-Regular (1-2 times/week)
___Sporadic (1-2 times/month)
___ None
2. Are you currently following a regular cardiovascular exercise training program?
____Yes ____No If yes, specify the type of exercise(s) ______
____minutes/day ____days per week
How long have you been following the regular cardiovascular exercise training program?
____months ____years
Rate your perception of the exertion of your cardiovascular training program.
____light ____fairly light/moderate ____somewhat hard ____hard
3. Are you currently following a regular resistance training program?
____Yes ____No If yes, specify the type of exercise(s) ______
____minutes/day ____days per week
How long have you been following the regular resistance training program?
____months ____years
Rate your perception of the exertion of your resistance training program
____light ____fairly light/moderate ____somewhat hard ____hard
4. Please rank your goals in undertaking exercise: Use the following scale to rate each goal separately.
Not at all important / Not important / Neutral / Somewhat Important / Extremely Important1 / 2 / 3 / 4 / 5
a. Improve cardiovascular fitness _____
b. Body-fat reduction/weight loss _____
c. Re-shape or tone my body _____
d. Improve performance for a specific sport _____
e. Improve mood and ability to cope with stress _____
f. Improve flexibility _____
g. Increase strength _____
h. Increase energy level _____
i. Feel better _____
j. Enjoyment _____
5. How much time are you willing to dedicate to an exercise program?
_____minutes/day _____days/week
6. What personal barriers/challenges tend to get in the way exercise?
______
______
______
7. What type of exercise interests you? Check all that apply.
_____ Cardiovascular Training _____ Circuit Training
_____ Strength Training _____ Weight Machines
_____ Free Weights _____ Flexibility/Mobility
_____ Sport-Specific Training _____ Group Exercise Classes
_____ Bodyweight Training _____ Other: ______
8. Is there anything else you would like your trainer to know before starting?
______
______
______
Campus Recreation
Fitness Assessment & Personal Training Liability Waiver
I agree to allow the UTSA Fitness & Wellness Staff to assess my level of fitness and/or design an exercise program for me to enhance my health & fitness goals. I have discussed my health and fitness goals with them and have provided them all relevant and necessary information about myself, including my health and physical well-being, to allow them to accurately assess my level of fitness and develop a safe and effective program for me.
I understand that in developing an exercise program for me, UTSA Fitness & Wellness Staff are not guaranteeing any specific results.
I understand that changes in my physical activity may affect my physical well-being. I accept all risk to my health, including injury or death, that may result from my participation in this Fitness Assessment and/or the program designed. I hereby release UTSA, its governing board, officers, representatives, employees and agents, from any and all liability for any and all claims and causes of action for loss of or damage to my property and for any and all illness and injury to my person, including my death, that may occur as a result of my participation in this Fitness Assessment and/or the program designed.
I further agree to indemnify and hold harmless UTSA, its governing board, officers, representatives, employees and agents from liability for the injury or death of any person(s) and damage to property that may arise, in whole or in part, from my negligent or intentional act or omission while participating in this Fitness Assessment and/or the program designed, whether CONTRIBUTED TO OR CAUSED BY ANY negligence of UTSA, its governing board, officers, employees or representatives, or otherwise.
I understand that this exercise program does not replace the expert advice or medical treatment of my own private doctor. I acknowledge that the Fitness & Wellness Staff are not medical doctors. I understand that their assessment of my physical well-being and the program they develop for me will be based upon the information I provide to them. I have given the Fitness & Wellness Staff all necessary information about myself to prevent any possible complications.
PERSONAL TRAINING POLICIES
· You must have a current Campus Recreation membership to participate. You must bring your ID to get into the facility.
· Your first appointment with your trainer will be a fitness assessment. This comes complimentary with your purchased sessions. Fitness assessments will give your trainer a chance to gather relevant information regarding your current health and fitness levels. Please show up to the fitness assessment in workout attire, as some of the assessments involve exercise and body measurements. You will be contacted within the next 3-4 business day to confirm an appointment date and time.
· After your fitness assessment, you and your trainer will schedule your sessions. To track your progress, your trainer will keep a log that you will sign after each session.
· To get the most out of your sessions be sure to dress comfortably and bring a water bottle. Also, feel free to take advantage of our free towel service.
· Cancellation Policy: Please notify trainers of any cancellations at least 24 hours in advance. Failure to do so will result in forfeiture of the session.
· Late Policy: Please arrive to your scheduled sessions on time. If you arrive late, your session will still end at the original scheduled time. If you arrive 15 or more minutes late, your session will be forfeited.
· Remaining Sessions: All sessions must be used within one year of purchase. If you have used all of your sessions and want to continue to be trained, you must purchase more sessions.
· Refund Policy: A partial refund of 80% is available before the first attended session. Once sessions have started no refunds will be given. If participant becomes physically unable to participate for an extended period a partial refund may be available given proper medical documentation.
· If you feel a personal trainer or other fitness staff does not provide a sufficient level of customer service, please contact the Fitness & Wellness office at (210) 458-6725.
Signature: Date: ______