Personalized Training Request Form

Transcription

1 Personalized Training Request Form Date Name Member # Birthdate Desired Dates & Times Phone Desired Instructor (staff bios on back) Please note the following: 1. Personalized Training is sold in package's of three, one hour sessions. If you would like half hour sessions, please discuss that with your instructor and you will be able to have six sessions. 2. We will NOT be issuing "partial refunds" for forgotten sessions. It is your responsibility to show up to each scheduled session and if you cannot make it you must call and cancel. 3. All sessions must be cancelled 24 hours prior to the time the session is scheduled. If you do not cancel 24 hours prior to the session, then that session counts as one of your sessions. If prior cancellation hasn't been made and you are more than 15 minutes late, then that counts as one of your sessions. 4. Online scheduling reminders are now available. Please provide your address so we can get your account set up. 5. Any scheduled sessions not paid for will be cancelled will be canceled after 6 months. Member s Initials Full Facility Member Pricing 1 One hour Session: $50 3 One hour sessions $ Please Circle Your Choice Program Member Pricing 1 One hour Session: $65 3 One hour sessions: $195.00

2 Get to Know Our Trainers Kim Dalmatoff: Personal Trainer and Nutrition Expert Kim started her fitness journey many years ago but has recently became Certified as a Personal Trainer. Once she obtained her certification, she realized how many other opportunities there are in fitness. Kim is also a Certified Spin Instructor and Body Pump instructor. She loves having fun while helping others be active and get in shape to reach their goals. She has worked to help condition an athlete who just wanting to improve their form, increase their stamina, then a incorporated a HIIT/Crossfit style which is her favorite. She also has the ability to scale workouts to basic foundational movements to help those recovering from injury to feel strong and confident again in a safe manor. Mad Dog Spin Instructor Certified Body Pump Certification Nutritional Health Coach Certification Barre TRX Specialty: Working with all ages and range of intensities to get you in shape quickly and safely Max Sandoval: Personal Trainer Max is a certified Personal Trainer through the National Association of Sports and Medicine. Max has a passion for fitness and focuses daily on helping others achieve their goals. Max teaches group training and personal training. His goal is to compete in an NPC Men s Physique Contest. American Red Cross Adult/Pediatric First Aid/CPR/AED Specialty: Max specializes in hypertrophy/muscle building training. Cheri Hays: Personal Trainer Cheri has been working in the fitness industry since 2010, and as a swim instructor since 1996 and has many years of experiences coaching. You may also see her lifeguarding, teaching, or training in our small group area at the YMCA. She really enjoys sharing her enthusiasm for fitness with others. TRX Certified Mad Dog Spin Instructor Certified 200 Hour Yoga Certified Swim Instructor Specialty: Working with all ages to help them reach their goals! Tony Mavros: Personal Training Tony is passionate about collaborating with clients to achieve their goals. He is equipped with nearly 15 years of experience in holistic physical medicine and rehabilitation. Tony delivers individual exercise programs with measurable improvements by blending wellness principles with fun and holistic purpose-driven focus. Tony strives ensures that exercises are safe for you to reach the level of fitness that you want to achieve. Certifications Bachelor s Degree in Exercise Science and Wellness, Bastyr University, WA Personal Trainer (NASM) Corrective Exercise Specialist (NASM) Massage Therapist (CMTC) Fitness Nutrition Specialist (NASM) Group Exercise Instructor (AFAA) Specialty: Neuromusculoskeletal postural balancing for youth to the elderly for the purpose of improving activities of daily living and athletic performance while preventing or managing chronic pain

3 Rosemary Lieberman: Personal Trainer Rosemary is a certified Personal Trainer through the National Association of Sports Medicine. Her passion and focus is on older adults seeking to improve their health and well being. As we age, there is a natural decline in our muscle tone, balance and flexibility. Rosemary s focus is on keeping our physical abilities and improving them for a continued healthy lifestyle. Rosemary is a Yoga, Pilates and Silver Sneakers Instructor. She has been teaching hatha yoga for close to 15 years and has experienced participants health increases through exercise. YMCA Group Exercise Silver Sneakers Instructor Certified 200 Hour Yoga Certified Specialty: She wants to share her knowledge and experience with those who are interested in improving their health and maintaining their life style. Lauren Polo-Esakoff: Personal Trainer As a former gymnast, Lauren made movement and exercise a priority in her life. Then, as a mother she was able to fine-tune her compassion, empathy, and the art of creating a balanced lifestyle into her fitness training. Lauren s focus now is on improving one s quality of life through her active aging exercise programs. Her expertise aids her in creating an exercise program that will improve balance, strength, flexibility, as well as building confidence to positively impact all aspects of daily living. National Academy of Sports Medicine (NASM) Senior Fitness Specialist Aerobics and Fitness Association of America (AFAA) Silver Sneakers Instructor Certified Livestrong Trainer/Coordinator. Specialty:: Longevity through an active lifestyle and tailoring fitness plans to reach personal goals Nadine Stilwell: Personal Trainer Nadine is a former competitive figure skater, competitive runner, and now a Crossfit Athlete.. Whether you re looking to improve your posture and balance, boost your mood, gain strength or endurance, enhance your daily activities, or to increase your lean mass, she can custom tailor a program for you that works. NASM certified Personal Trainer. ACE Group Exercise Certification Les Mills Body Pump Certification Les Mills CXWorx Certification. Specialty: Her passion is to empower her clients to find their own personal path to wellness

4 Personal Training Questionnaire Date: Trainer Request: Name: Date of Birth: Gender: Contact Information: Phone Number: Address: Physician s Name: Emergency Contact Name: Relationship: Phone Number: PAR-Q Pre-exercise Questions Yes No Has your doctor ever said that you have a heart condition and that you should do only physical activity recommended by a doctor? Yes No Do you feel pain in your chest when you do physical activity yes No In the past month have you had chest pain when you were not doing physical activity? Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing drugs (for example water pills) for your blood pressure/heart condition? Yes No Do you know of any other reason why you should not do any physical activity? Please Explain any yes answers:

5 Yes No Have you had a recent surgery in the last 12 months? Yes No Are you pregnant or postpartum in the last 3 months? Yes No Do you have a muscle, joint, back disorder or any existing injuries? Yes No Do you have any orthopedic problems, including arthritis? Yes No Are you accustomed to vigorous activity? Please Explain any yes answers: Personal Training Questions: Mark the days of the week you are available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday What training sessions are you interested in? 30 Minute 1 Hour Group Training Specialty (TRX, Kettlebell) What types of exercises are you currently engaged in? What types of exercises interest you: Walking jogging Swimming Strength Training Pilates Yoga Others: What are you looking for in a trainer?

6 Initial Physical Assessment (completed by trainer) Date: Weight: Height: Body Fat %: TargetWeight Goal: Chest Waist Hips Thight Arm L Arm R Agreement I understand that I will be charged if I do not give at least 24 hours notice prior to any scheduled sessions. I agree to work with my trainer towards my goals. I realize that results will not happen overnight and that things worth having are worth working for! Signature: