Thank you again and please feel free to contact me with any questions regarding our private pilates program offerings.

Transcription

1 Dear Client: Thank yu fr yur participatin in a persnal service frm The University f Pennsylvania s Department f Recreatin. We are lking frward t prviding yu with a psitive experience and assisting yu with the achievement f yur persnal health, fitness, and wellness gals. Please take a few minutes t review and cmplete the enclsed prgram registratin and release f liability frm, client infrmatin sheet, health histry questinnaire, prgram plicy frm, and prgram infrmed cnsent. These frms will prvide ur health and fitness prfessinals with the required infrmatin necessary t begin yur service. Shuld we have any questins regarding yur paperwrk yu will hear frm us shrtly. Otherwise, yu can expect t hear frm yur assigned instructr within five (5) business days. Thank yu again and please feel free t cntact me with any questins regarding ur private pilates prgram fferings. Sessins Purchased: f Purchase: f Expiratin: Single sessins and packages up t 5 sessins expire 90 days frm the ORIGINAL DATE OF PURCHASE. Packages f 10 r mre sessins expire 120 days frm the ORIGINAL DATE OF PURCHASE.

2 Welcme t the Department f Recreatin s Pttruck and Fx Health and Fitness Centers. Our plicies have been develped with the intentin f prviding all members with a clean, safe and welcming envirnment. Please bserve ur cre plicies listed belw during yur use f the facility: We recmmend cnsulting a physician and receiving prper clearance prir t beginning an exercise prgram. Exercising may cause cnditins such as dizziness, exhaustin, r ther signs r symptms that may put yu at risk fr injury. If yu experience any f these r ther physical abnrmalities, immediately stp exercising and cntact the facility staff n duty. Please reprt any persnal injuries immediately t the facility staff n duty. We recmmend participating in an rientatin with a member f ur fitness team t understand the prper use f ur equipment prir t beginning yur rutine. Please place all persnal items in a lcker. Bags, extra clthing, and ther persnal items are nt permitted in the fitness center. Please refrain frm eating fd, chewing gum, and/r drinking any beverage ther than water r sprts drink in an enclsed plastic cntainer in the facility. Please limit yurself t 30 minutes n all cardivascular equipment. Please wipe dwn all equipment including cntrls, handles, seats, and pads when yu are finished with yur wrkut. Please use all exercise equipment as specified by the manufacturer fr its intended use. Mving r mdifying the use f the equipment is nt permitted. We recmmend the use f a sptter and cllars n all bars when training with free weights. Please raise and lwer all machines and free weights carefully; avid drpping r banging the equipment n the flr. Please return all free weight plates, bars, dumbbells, cllars, medicine balls, stability balls, and any ther miscellaneus equipment t their apprpriate strage rack when finished. Please bserve ur dress cde plicy. Nn-casual athletic ftwear, t-shirts, and athletic shrts/pants must be wrn at all times. Bts, pen te ftwear, excessive jewelry, jeans, nn-athletic pants/shrts, and revealing clthing is nt permitted in the fitness center. Please cnduct yurself in a respnsible manner at all times. Inapprpriate r abusive language, aggressive behavir, smking, smkeless tbacc, r the use f drugs and/r alchl is nt permitted in the fitness center. Please see a staff member regarding prgrams and services. Members and guests are nt permitted t prvide persnal training services, nutritinal prducts, r thers gds and services in the fitness center. Fr a cmplete list f plicies and prcedures, please visit

3 NAME: DAY PHONE: PENN ID: EVENING PHONE: UNIV. STATUS: PROGRAM: PRIVATE PILATES # OF SESSIONS: OFFICE USE ONLY- INSTRUCTOR ASSIGNED: 1. In cnsideratin f gaining membership r being, allwed t participate in the activities and prgrams f the Trustees f the University f Pennsylvania and t use its facilities and equipment, in additin t the payment f any fee r charge, I d hereby waiver, release and frever discharge the Trustees University f Pennsylvania and its fficers, agents, emplyees, representatives, executrs, and all thers frm any frm any and all respnsibilities r liability fr injuries r damages resulting frm my participatins in any activities r my use f equipment in the abve mentined facilities r arising ut f my participatin in any activities at said facility. I d als hereby release all f thse mentined and any thers acting upn their behalf frm any respnsibility r liability fr any injury r damage t myself, including thse caused by the negligent act r missin f any f thse mentined r thers acting n their behalf r in any way arising, ut f r cnnected with my participatin in any activities f the Department f Recreatin r the use f any equipment at the University f Pennsylvania. (Please initial : ) 2. I understand and am aware that strength, flexibility, and aerbic exercise, including the use f equipment, are a ptentially hazardus activity. I als understand that these activities invlve a risk f injury and even death and that I am vluntarily participating in these activities and using equipment with knwledge f the dangers invlved. I hereby agree t expressly assume and accept any and all risks f injury r death. (Please initial : ) 3. I d hereby further declare myself t be physically sund and suffering frm n cnditin, impairment, disease, infirmity, r ther illness that wuld prevent my participatin in any f the activities and prgrams f the Trustee f the University f Pennsylvania r use f equipment except as hereinafter stated. I d hereby acknwledge that I have been infrmed f the need fr a physician s apprval fr my participatin in an exercise/fitness activity r in the use f exercise equipment and machinery. I als acknwledge that it has been recmmended that I have a yearly r mre frequent physical examinatin and cnsultatin with my physicians as t physical activity, exercise, and equipment use. I acknwledge that I have either had a physical examinatin and have been given any physician s permissin t participate, r that I have decided t participate in activity and/r use f equipment withut the apprval f my physician and d hereby assume all respnsibility fr my participatin and activities, and utilizatin f equipment in my activities. (Please initial : ) Signature

4 Name: : # f Lessns: Please circle/answer the fllwing questins in rder t prvide us with pertinent infrmatin that will aid in the develpment f yur persnalized training prgram. 1. Is this yur first time wrking with a Pilates instructr? Yes N 2. Why have yu decided t participate in the Penn Pwer Pilates Prgram? 3. D yu currently exercise? Yes N If n, have exercised in the past? Yes N Hw lng it has been since yu have perfrmed rutine exercise at least 3x/week? 0-6 mnths 6-12 mnths >1 year 4. Please list yur persnal health and fitness gals in rder f imprtance: 5. Please list any additinal activities that yu are currently participating in r have participated in the past (sprts, recreatinal hbbies, walking, cycling, grup exercise classes, etc.): 6. Please describe any limitatins/restrictins that yur instructr shuld be made aware f prir t beginning yur persnalized prgram? 7. Please circle what day(s) are best fr yu t cmmit t yur private Pilates sessins? Mnday Tuesday Wednesday Thursday Friday Saturday Sunday 8. Please circle what time(s) are best fr yu t cmmit t yur private Pilates sessins? 6-9 AM 9-12 PM 12-3 PM 3-6 PM 6-9 PM Instructr Assigned: : Initials: OFFICE USE ONLY Health Histry Questinnaire Yes N Infrmed Cnsent Yes N POTTRUCK CENTER Prgram Plicy Yes N

5 Tday s : Name: Age: f Birth: Address: City: State: Zip: Hme Phne: Wrk Phne: University Status: Student Faculty/Staff Other Sex: M r F Height: Weight: Physician s Name: Phne #: D yu currently exercise? Yes N If n, have exercised in the past? Yes N Hw lng it has been since yu have perfrmed rutine exercise at least 3x/week? 0-6 mnths 6-12 mnths >1 yr. Name: Phne #: This frm is nt a substitute fr a thrugh physical examinatin, assessment and diagnsis by yur physician. It is designed t identify adults fr whm physical activity might be inapprpriate at this time. The Department f Recreatin strngly recmmends that each member underg a medical examinatin befre beginning any exercise prgrams. HAVE YOU EVER BEEN DIAGNOSED WITH, OR DIAGNOSED WITH THE FOLLOWING: Heart Attack/Heart Disease Crnary Bypass Emblism Pacemaker Aneurysm Diabetes Mellitus (Req. Insulin Therapy) Angina Pectris High Bld Pressure (Req. Medicatin) Strke Epilepsy r Seizures If yu checked any f the abve cnditins, yu MUST have medical clearance prir t exercising and rientatin.

6 Male ver 45 r female ver 55? D Yu Smke? If n, have yu quit within the previus 6 mnths? Have yu had majr surgery r been hspitalized within the past year? Are yu currently pregnant? If yes, when are yu due? Asthma and Allergies (req. medicatin) Brnchitis Cancer (please specify: ) Crnary Heart Disease (heart attack, bypass surgery, chest pain, heart murmur, irregular heart rhythm, ther) Diabetes Family Histry f Heart Disease (heart attack r sudden death in males <55 years and females <65 years f age) Gastric Reflux r Heartburn High Bld Pressure High Chlesterl Kidney Disrder Liver Disease Sleep Disrders (including Apnea) Surgical Weight Reductin Prcedure (gastric bypass, laparscpic band, etc.) Strke Thyrid Cnditin Other nt listed (please specify: ) If yu checked any f the abve bxes, please prvide further details: Are yu presently under medical care, supervisin, under restrictins frm yur physician fr any ther health related issues? If yes, please explain: Arthritis Bne Cnditins (fractures, lw density, vitamin and mineral deficiencies, steprsis, ther) Chirpractic Care Chrnic jint prblems Physical Therapy Past injuries frm physical activities, accidents, etc. If yes, please explain:

7 Is there any ther medical cnditin nt mentined that may limit yur physical activity: Please list all prescriptin and/r ver the cunter medicatins yu currently take: Please list all vitamins, minerals, and nutritinal supplements yu currently take: I understand the nature f the Health Histry Questinnaire and I am aware that any strenuus physical activity invlves risk. Accrdingly, I release, discharge, abslve, and hld harmless the University f Pennsylvania, the Department f Recreatin and Intercllegiate Athletics, the Penn and Katz Fitness Centers, and Fitness Instructrs r student emplyees, and all assciated frm any and all liability arising ut f any accident, injury, r lss sustained by me as a result f activities at r present in the Fitness Centers lcated at Hutchinsn Gymnasiums and the David Pttruck Health and Fitness Center. I declare, t the best f my knwledge, that all my answers are true, crrect, and cmplete. Client Signature Pilates Instructr Signature (Department f Recreatin representative)

8 Each lessn is based n a 60 minute wrkut. T get the mst ut f ur effrts, please be ready t exercise at the appintment time. Keep in mind that when yu are late t a sessin, it will end at the scheduled time. If yu are mre than 30 minutes late, it will be cnsidered a n-shw and yu will be charged. Please wear lse, cmfrtable clthing t facilitate ease f mvement, alng with apprpriate athletic ftwear. Yu are required t fllw all psted facility rules and regulatins while wrking with a Pilates instructr. The Pilates instructrs are available by APPOINTMENT ONLY Mnday thrugh Friday, 7 AM 7 PM. Lessns befre r after this time perid r n the weekends may be requested, but nt always available. Scheduling early mrning, late evening, r weekend lessns are under the discretin f yur assigned Pilates instructr, hwever the instructrs are nt bligated t entertain these time frames. All lessns must be paid fr in advance. This will reserve a scheduled time slt and help yu cmmit t yur gals. Pilates instructrs are nt permitted t receive payments. All payments must be made at the Department f Recreatin Membership Services Office lcated in the Pttruck Center. Check, credit card (visa r mastercard nly), and cash (exact change nly) payments are accepted. Checks are t be made payable t The Trustees f The University f Pennsylvania. Payments made utside f these terms will result in terminatin f all membership privileges t the Department f Recreatin. Lessn payments are nn-refundable, but they may be transferred fr anther prgram r service if still valid. Transfer permissin must be btained frm the Assciate Directr fr Prgrams. 3 and 5 sessin packages expire 90 days frm the ORIGINAL DATE OF PURCHASE. Packages f 10 r mre sessins expire 120 days frm the ORIGINAL DATE OF PURCHASE. Yu, as the client, have the ability t cancel at any time. As a prfessinal curtesy, a 24 hurs ntice is required when canceling an appintment. If yu d nt prvide 24 hurs ntice, yu will be charged fr that sessin. Cancellatin requests must be cmmunicated directly t yur assigned Pilates instructr. During yur initial cntact with yur instructr yu will receive his/her cntact infrmatin. Please retain this infrmatin fr yur recrds. In an extreme circumstance, the situatin will be reviewed. Extreme circumstances include, but are nt limited t, sudden unexpected car truble, illness, uncntrllable life events, emergencies, etc. The assigned Pilates instructr des have the right t ask fr prf f any such incident. If there shuld be a discrepancy, the ultimate decisin will be left t the Assciate Directr fr Prgrams. I acknwledge and fully understand the Prgram, Payment, and Cancellatin Plicy stated abve. Client Signature Pilates Instructr Signature (Department f Recreatin representative)

9 I have enrlled in a prgram f physical activity ffered by the Pilates Prgram, Department f Recreatin at the University f Pennsylvania (cllectively referred t as Penn). I understand that my participatin in this prgram is vluntary and I affirm that I am in gd physical cnditin. I may discntinue my participatin at any time and may chse nt t participate in any activity. As evidenced n the Health Histry Questinnaire, I have advised the staff f any and all medical cnditins including but nt limited t disease and/r injuries I may have and the use f any medicatins that may effect r limit my participatin r use f any specific equipment r activity. I in exchange fr gd and valuable cnsideratin, hereby waive and release the Trustees f the University f Pennsylvania, the Department f Recreatin, the Pilates Prgram, their emplyees, as well as students and vlunteers frm and against all claims, demands and damages f any srt and frm whatever cause because f my being upn these premises and participatin in this prgram. I understand that I may be injured as a result f my participatin in this prgram r as the result f the cnduct f anther. I further release and hld harmless Penn frm all injuries, including serius injuries and death, directly r indirectly related r unrelated t my participatin in this prgram. I understand that Penn will in n way bear respnsibility fr medical bills r related expenses pertaining any injury r incidents that may ccur at any time. I have had an pprtunity t ask any questins f my instructr r staff f the Department f Recreatin regarding this prgram. I understand that there are risks assciated with any physical activity prgram. In the event that I am injured r ill at any pint during r after my participatin in this prgram I will immediately ntify my instructr and the Department f Recreatin. As evidenced by my signature belw, I agree t abide by the Rules and Regulatins f the Department f Recreatin and I agree I have read and fully intend t cmply with the cntents f this dcument. Client Signature Pilates Instructr Signature (Department f Recreatin representative)