Fitness Fever Requirements Application Process Upon acceptance into the Fitness Fever program, participants will receive Application Checklist
|
|
- Gwenda Johnson
- 5 years ago
- Views:
Transcription
1 Fitness Fever Requirements Able to commit two to three hours a week Complete participant packet Participate in two group workouts a week and participate in one other exercise activity Program cost University of Maryland Students and SMC Campus Center URecFit Members applicants will have first priority o $50 for University of Maryland Students o $75 for SMC Campus Center URecFit Members o $125 for Non-Members (includes gym usage privileges for the duration of the program) Application Process Applications accepted Nov. 19 through Jan. 8, 2018 The packet must be completed in its entirety to be turned in All applicants will be ed by Jan. 11, 2018 at 5pm to be informed of their acceptance status The program fee is due by Jan. 13, 2019 at 10pm. Payment will be done at the business desk No refunds will be given after the close of the Kick-off Event Upon acceptance into the Fitness Fever program, participants will receive two Group Training Session a week to be guided by personal trainers/instructors Weekly Weigh-ins Motivational Coaching and nutrition tips T-shirt Application Checklist Before submitting this application packet, please make sure the following is included: Completed Participant Application Waiver Health History PAR-Q and You Physician s Statement and Clearance form is required to be completed if YES is checked to one of more questions Photograph and Publicity Form Questions can be directed to Jimmy Mszanski, Assistant Director of Fitness jmszanski@umaryland.edu,
2 Name Local Address Apt/Box # City State Zip Phone Male Female Weight Desired weight Height Age Student Member Other Program/Department Shirt Size S M L XL XXL XXXL How did you hear about us? AGREEMENT I agree to pay the fee by Jan.13, 2019 if selected to participate in URecFit s Fitness Fever Signature Completed applications are due to the Business Operations Desk on the 4 th floor attn: Jimmy Mszanski no later than Jan. at 5pm. Participants will be notified of acceptance into the program via by Jan. 10, 2019 by 5pm. Some participants may be required to obtain a doctor's note prior to participating in the program. SPRING 2019 Jan - March AVAILABILITY Please list all times you are available on a weekly basis Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Date 8 Print Name Date of Birth: / / 2
3 Waiver of Liability Initial: In consideration of permission to use the property, facilities, staff, equipment, services, and programs of University Recreation & Fitness ( URecFit ), I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, and discharge the University System of Maryland (USM), the University of Maryland, Baltimore (UMB), URecFit, Southern Management Corporation Campus Center (SMC CC), and Wexford UMB 2, LLC (Wexford), and their regents, directors, officers, employees, and agents from liability from any and all claims, including but not limited to negligence, claims of physical or mental injury, illness (including death), and property loss arising from participation in URecFit facilities, activities, classes, and observation, and use of URecFit facilities, premises, and equipment. Assumption of Risk Initial: Physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. URecFit and UMB have facilities for, and provides for, activities such as weight lifting, running, aerobic activities, group fitness, classes, instructional, outdoor adventure, and sporting activities. Some of these involve strenuous exertions, some involve quick movements, and others involve sustained physical activity, which places stress on the cardiovascular system. Specific risks vary from one activity to another, but the risks range from (1) minor injuries such as scratches, bruises, and sprains; (2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions; (3) catastrophic injuries including paralysis and death. I understand the risks that are inherent in activities made possible by URecFit. I agree that my participation is voluntary and I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of URecFit or others, and I assume full responsibility for my participation. Indemnification and Hold Harmless Initial: I agree to indemnify and hold harmless the USM, UMB, URecFit, SMC CC, Wexford, and their regents, directors, officers, employees, and agents, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney s fees, for claims related to my involvement at URecFit sponsored activities. Severability Initial: I agree that this Waiver of Liability, Assumption of Risk, and Indemnification Agreement may be broadly construed in favor of URecFit as permitted by the law of the State of Maryland and that if any portion of this Agreement is held invalid, the balance shall continue in full legal force and effect. Acknowledgment of Understanding I certify that I am at least eighteen (18) years of age, and that I have read and I understand this Agreement as indicated by my initials above and my signature below. I acknowledge that I am signing this Agreement freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability. If I do not agree to any of the terms of this Agreement, I understand I do not need to sign it, and I may forego participating in the facilities and activities of URecFit as the alternative. READ AND UNDERSTOOD: Signature: Date: / / If the person is under 18 years of age: The Applicant is under 18 years of age; he or she must also have a Parent or Guardian s signature to participant. This entire form is Read and Understood by the Parent/Guardian. 3
4 PERSONAL MEDICAL HISTORY Physician s Name Health History Physician s Number Have you had any past operations, hospitalizations, disabilities, diseases or are you currently under a physician s care: Have you ever been diagnosed with the following? Please check all that apply and write the date and a description below. Date and Description Heart Attack High Blood Pressure High Cholesterol Rheumatic Fever Heart Murmur Seizure/epilepsy Stroke High Blood Triglycerides Blood Clots Cancer Diabetes Asthma Gout Arthritis Osteoporosis Exercise-induced Asthma Thyroid Disorders Allergies Varicose Veins Hernia Obesity Anorexia Bulimia Severe Headaches Kidney Failure Kidney Removal Kidney Stones Kidney Dialysis Colitis Gall Bladder Removal Fibromyalgia Anemia Pregnancy Gall Bladder Disease/stones 4
5 SYMPTOMS REVIEW Have you ever experienced the following during exercise, after exercise or during a resting state? Please check all that apply. Shortness of breath or wheezing Side aches or side stitches Middle back pain Extremely high heart rate Irregular heart rate Shoulder pain Sharp Chest Pain Dull aching chest pain Foot or ankle pain Overall or one-sided weakness Loss of coordination Knee pain Heat intolerance Dizziness Low Back pain Mental Confusion Fainting Calf pain Vomiting Swelling of ankles or hands Hip pain/sciatica Cramping Shin Splints Arm or neck pain MEDICATIONS Please check all that apply and describe side effects Digitalis Anti-arrhythmias Diuretics and Electrolytes Metabolics Beta Blockers Tranquilizers or sedatives Vasodilators Alpha Blockers Calcium Channel Blockers Other Anti-inflammatory (Motrin, Advil) INJURY HISTORY Have you ever suffered an injury at any of the following joints? If yes, please describe severity and frequency. Ankle (R or L) Knee (R or L) Hips Low Back Shoulder (R or L) 5
6 Neck Other Do any of the joints above bother you during exercise? Yes, please explain below No FAMILY HISTORY Please check if anyone in your immediate family (grandparents, parent, and siblings) experienced any of the following. Relationship Age Description Heart Attack or stroke before age of 55 Heart Surgery High Cholesterol High Blood Pressure High Blood Triglycerides Diabetes Cancer Alzheimer s Heart Operations Congenital Heart Disease Early death Other family illness LIFE STYLE QUESTIONAIRE Please check all that apply. Do you smoke? No Yes Former Smoker If you checked yes please select from the following Cigarettes Cigar Pipe If you checked any of the following, how many do you smoke a day? If you checked any of the following, how many years have you smoked? If you checked the following, how long ago did you stop smoking? Do you drink alcoholic beverages? Yes No 6
7 If you checked yes to the above question, how much do you drink (in ounces) in an average week? Do you drink caffeinated beverages? Yes No If you checked yes to the above question, how many cups a day? Please rate your Daily Stress Levels (select one) Low Moderate High-but I enjoy the challenge High-sometimes difficult to handle High-often difficult to handle Describe what you eat on a typical day, give specific examples and included time of day. Breakfast Lunch Dinner Other Recent Exercise Habits How many times per week are you physically active? When you are physically active, how long does it last? On a scale from 1 to 10, how intense is your typical activity? (10 being highest) How many years have you been exercising? In a typical week, how many minutes do you spend in the following activities? Running/jogging: Racquet Sports: Biking: Yoga: Walking: Swimming: Skiing: Pilates: Aerobics: Weight Training: Stair Climbing: 7
8 8
9 Physician s Statement and Clearance Form Licensed Medical Physician s clearance to participate in a progressive exercise program is requested for: Client s Name: Date of Birth: Physician s Name: Physician s Phone: The University of Maryland, URecFit s Fitness Fever Program provides a variety of fitness opportunities for the University community. These activities may be vigorous in nature and are usually challenging to the individual s cardio respiratory and muscular systems. The individual may be involved in a class, personal training and/or self directed type of exercise program. It is my understanding that will be participating in a fitness evaluation and/or exercise program. I understand that the aspects of the program will include the following. 1 Physiological tests including: 1. Resting heart rate and blood pressure 2. Body composition (skin folds) 3. Abdominal Strength: Curl-ups and Push-ups 4. Cardiovascular testing 5. Flexibility: Sit and Reach 6. Other: 2 Exercise program including: 1. Strength training using weights, body weight, bands, etc. 2. Cardiovascular exercise 3. Other: Please list any recommendations or restrictions that are appropriate for your patient in this exercise program: As the individual s attending physician, I am not aware of any medical condition that would prevent him/her from participation in the exercise outlined above. Physician s Signature Date Phone Thank you for taking the time to fill this out. Please return the form to: URecFit Jimmy Mszanski Assistant Director Fitness 621 W Lombard St, Room 509 Phone: (410) Fax: (410)
10 Photograph and Publicity Agreement Form I,, give the UM URecFit permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of UM URecFit. I agree that UM URecFit have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the URecFit missions. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I have read and I understand this Agreement above as indicated by my signature below. I acknowledge that I am signing this Agreement freely and voluntarily. If I do not agree to any of the terms of this Agreement, I understand I do not need to sign it, and I may forego participating in the facilities and activities of URecFit as the alternative. READ AND UNDERSTOOD: Signature Dat 10
11 11
Personal Training New Client Packet Personal Training/Fit for Hire
Personal Training New Client Packet Personal Training/Fit for Hire Date / / Name Address City State Zip Phone Number Email Trainer Preference Male Female No Preference **If you would like to work with
More informationWaiver, Release and Hold Harmless Agreement Personal Training Services
Waiver, Release and Hold Harmless Agreement Personal Training Services I,, the undersigned, affirm that I am participating voluntarily in Personal Training Services. (Print name) I (together with my parent
More informationJumpstart, Fitness Assessment, & Body Composition
Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training
More informationName: Date: Address: City: State: Zip: Birthday: / /
PERSONAL TRAINING Name: Date: Address: City: State: Zip: Birthday: / / Sex: Male Female Name of Gym: Occupation: Phone (home): Phone (work): Body Weight: Body Fat: Height: Personal Goals 1. Primary Training
More informationThanks again, The BodyEvolver team Fitness Technology Partners, LLC bodyevolver.com
Thank you for downloading this comprehensive client intake package. It is our pleasure to provide this tested document which we know will help your business. A complete on-line version of this intake package
More informationMEMBERSHIP APPLICATION
MEMBERSHIP APPLICATION Join Date: Full Pay Draft 20/20 Membership Type: Household One Parent Household Two Adult Household Senior Household Adult Young Adult Youth Senior First Name MI Last Birth Date
More informationPersonal Training Registration Packet
Personal Training Registration Packet Client Name: Date: Program Information and Policies Welcome to the UCSB Personal Training Program! We are delighted that you chose us as a part of your commitment
More informationUCSB Olympic Weightlifting Platform Area Specific Policies, Safety, and Liability Protocol
Patron Name: r Staff / Faculty r Community Member r Student Exp. Grad year UCSB Olympic Weightlifting Platform Area Specific Policies, Safety, and Liability Protocol Patron please initial each item: 1.
More informationPersonal Training Health Screening Questionnaire
RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:
More informationColorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire
Colorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire Client Name: Today s : Contact Number: E-Mail: Occupation: Age: How did you hear about us? Have you ever had a
More informationClient Contact Information. Training Information
Client Contact Information Name Address (Street) (City) (State) (Zip) Home Phone ( ) Cell Phone ( ) Work Phone ( ) Email Date of Birth / / Training Information Type Personal Training - $35 Partner Training
More informationWelcome to the CANYON WELLNESS PROGRAM!
Welcome to the CANYON WELLNESS PROGRAM! This program is designed to allow you to continue/initiate the pursuit of your health/wellness goals. You may have just completed a course of Physical Therapy or
More information*Your address will be added to our WODIFY system. You may receive correspondence from both WODIFT and Crossfit Toowoomba from time to time.
Name: Date of Birth: Emergency Name and Contact No: Address: Contact Number: Email Address Occupation: Have you done Crossfit Before? Gender: If so where? *Your email address will be added to our WODIFY
More informationSpring 2018 Small Group Training Registration
Spring 2018 Small Group Training Registration Small Group Training Information Packet General Information Session Dates: Monday, February 19 th - Thursday, April 20 th (8 weeks) Free class demos will be
More informationBody Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information
Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY 40517 (859) 268-8190 General Information Full Name Birth date / / Date / / Social Security # - - Driver s License
More informationREQUIREMENTS: PROGRAM INCLUDES: IMPORTANT DATES: CHALLENGE WINNERS: HOW DO I PARTICIPATE IN AUBURN STRONG?
REQUIREMENTS: Auburn University student, faculty or staff Physician clearance/par Q Completed registration form 3 day food log prior to nutritional assessment Nutritional Assessment Attend @ least 2 semi-private
More informationComplete enrollment packet and schedule a time to meet with Louie Morphew.
Fitness Intake Packet (Personal Training and Adaptive Fitness Clients) Please follow the step-by-step instructions listed below. If you have any questions or concerns, please e-mail Louie Morphew at Lmorphe1@msudenver.edu.
More informationClient Assessment Readiness Questionnaire
Client Assessment Readiness Questionnaire The following questions will help determine your level of readiness for change, your motivation towards reaching your goals, and identifying obstacles to your
More informationColorado Mesa University Campus Rec Services Personal Training Request Packet
Colorado Mesa University Campus Rec Services Personal Training Request Packet Personal Training Services are a fee-based service available to current CMU students, Faculty & Staff membership holders, as
More informationGym Memberships. The cost of the membership is per month, plus a one off cost of 5 for the band.
Gym Memberships Membership Form Name: Address: Membership Start Date: Payment Details The cost of the membership is 18.50 per month, plus a one off cost of 5 for the band. This Payment should be made either
More informationDepartment of Campus Recreation: SouthFit Personal Training
Steps to sign up Step 1: Choose the personal training package that you would like on page 2. Personal training is only available to members of the USA Student Recreation Center. Step 2: Fill out all pages
More informationFITNESS ASSESSMENT & WAIVER
Nutrition Counseling & Services/ Eat Well, Be Fit! www.eatwellbefit.com FITNESS ASSESSMENT & WAIVER Client Name: Date: Date of Birth: Age: Sex: Address: City: State: Zip: Phone: (Home): ( ) (Work): ( )
More informationDeKalb Medical Wellness Center 2665 North Decatur Road, Suite 10 Decatur, Georgia Membership Application
DeKalb Medical Wellness Center 2665 North Decatur Road, Suite 10 Decatur, Georgia 30033 Membership Application Member #: 2 nd Member #: Welcome! The information you provide below will be entered into our
More informationTrees Hall. Bellefield Hall
Classes Begin: Monday, 5/7/2018 Classes End: Friday, 8/10/2018 No Class: Memorial Day: 5/28/2018 & Independence Day: 7/4/2018 Trees Hall Indoor Cycling 4400 Monday / Wednesday 12:00-12:55 PM HFC Indoor
More informationFORMS 1) PAR Q & YOU:
Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the Vanderbilt Recreation & Wellness Center (the Rec)
More informationFITNESS CONSULTATION JOURNAL
FITNESS CONSULTATION JOURNAL 1 Table of Contents Guide to the ProFitness Program 2 Personal Information 3 Pre-Consultation Instructions 3 Personal Fitness Profile / History 4 Medical History 5-6 Injuries
More informationPersonal Training Intake Form
Personal Training Intake Form Name: Date: Cell Phone: Office Phone: E-Mail: USC Affiliation: STUDENT ALUMNI FACULTY/STAFF FACULTY/STAFF SPOUSE Sex: Male Female Age: Trainer preference (if any): How many
More informationSTRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING
STRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING Please take the time to read through all the information and ensure all relevant forms are completed. The following questionnaire and waivers
More informationCONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!
2017-18 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2017-18 year. Please return all completed
More informationNutrition Solutions, LLC Cancellation Policies
, LLC Cancellation Policies Thank you for choosing. Our mission is to educate, inspire and guide you to better health and wellness with balanced nutrition. Due to high demand for appointments we ve had
More informationTrees Hall. Bellefield Hall. Add a Fitness Center Membership for a small additional price!
Classes Begin: Tuesday, 9/5/2017 Classes End: Friday, 12/8/2017 No Class: Labor Day: 9/4/2017 & Thanksgiving Break: 11/23-24/2017 Trees Hall Kettle + Conditioning Fitness Kickboxing Fitness Kickboxing
More informationPersonal Training Registration Packet
Registration Packet Client name: Sessions Purchased: 3 Sessions 30 Minutes 60 Minutes 5 Sessions 10 Sessions 15 Sessions Purchase Date: General and Healthy History Questionnaire Name: Penn ID: Date of
More informationSMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC PHYSICAL THERAPY PATIENT INFORMATION CITY: STATE: ZIP CODE:
PHYSICAL THERAPY PATIENT INFORMATION DATE: NAME: DATE OF BIRTH: ADDRESS: CITY: STATE: ZIP CODE: *E-MAIL: HOW DID YOU HEAR ABOUT SMITH PHYSICAL THERAPY AND RUNNING ACADEMY? EMERGENCY CONTACT: REFERRING
More informationName (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
More informationGEORGE MASON UNIVERSITY PERSONAL TRAINING REGISTRATION FORM NEW CLIENT
GEORGE MASON UNIVERSITY PERSONAL TRAINING REGISTRATION FORM NEW CLIENT PLEASE PRINT, COMPLETE, AND DELIVER THIS FORM TO THE AQUATIC and FITNESS CENTER, RAC, OR SKYLINE FITNESS FRONT DESK: Ethan Carter
More informationRISK REVIEW & PHYSICIAN APPROVAL FORM
RISK REVIEW & PHYSICIAN APPROVAL FORM Burke Restorative Neurology Clinic is offering services meant to target community members with neurological impairments. The program is supervised by medical professionals
More informationMEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
More informationATHLETE START UP QUESTIONNAIRE The first step in the coaching process is filling out the athlete questionnaire. Once completed, back to me.
ATHLETE START UP QUESTIONNAIRE The first step in the coaching process is filling out the athlete questionnaire. Once completed, email back to me. General/Medical 1. Name 2. Address 3. E-mail 4. Phone Best
More informationUniversity of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS
Name (Last, First, MI) University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS of Birth Address Sex M / F Sport Phone City State Zip
More informationCity State Zip. Home Phone Mobile Phone. Can we text you appointment reminders? Yes / No If yes, who is your wireless carrier?
CryoBoost Lubbock 5206 82 nd St., Suite 15 (inside Austin Chiropractic) CryoBoost Allen 801 S Greenville Ave., Suite 115 (inside Wellness) Physical Readiness Questionnaire Name Date Address City State
More informationWellness Department. Non-Resident Pool Membership Packet. Page 1
Wellness Department Non-Resident Pool Membership Packet Page 1 Dear Non-Resident, Thank you for your inquiry into the Aquatic programs at Brethren Village. We offer the opportunity for residents in the
More informationParticipant Information Exercise Equivalent Chart Weekly Activity Log Participation Agreement Waiver and Indemnity Agreement
Participant Information Email Exercise Equivalent Chart Weekly Activity Log Participation Agreement Waiver and Indemnity Agreement PLEASE POST THIS EMAIL ON COMMON USE AREA BULLETIN BOARDS AT YOUR UNIT
More informationPAR-Q & LIABILITY WAIVER
PAR-Q & LIABILITY WAIVER Full name: Address: Post code: Mobile: Home phone: Email address: Date of Birth: Occupation: Emergency contact name: Relationship to you: Emergency contact phone number: Tara Blackaby
More informationPhysical Readiness Questionnaire
Physical Readiness Questionnaire Date Customer Name Address City State Zip Date of Birth H Phone Cell Phone Email Sex: M F Height Weight How did you hear about this Cryo Sauna Location? FOR MINORS ONLY:
More informationRecovery and Wellness through Cryotherapy Egan Drive* Suite 191* Savage, MN 55378* *cryostrong.com. Physical Readiness Questionnaire
CRYOSTRONG WHOLE BODY CRYOTHERAPY Recovery and Wellness through Cryotherapy 6001 Egan Drive* Suite 191* Savage, MN 55378*952-220-2997*cryostrong.com Physical Readiness Questionnaire Date: Customer Name:
More informationWarrior Personal Training Registration Packet
Warrior Personal Training Registration Packet Information and Policies This is personal training tailored to help you reach your desired fitness level. Your exercise program will be personalized to help
More informationPersonal Training Information Packet
Personal Training Information Packet Dubuque Community YMCA/YWCA 35 North Booth Street Dubuque, Iowa 52001 P 563.556.3371 F 563.556.2728 www.dubuquey.org Dear Member: Congratulations! You have just taken
More informationEau Claire Tower Fitness Centre MEMBERSHIP APPLICATION
Eau Claire Tower Fitness Centre MEMBERSHIP APPLICATION SHADED AREAS FOR OFFICE USE ONLY MEMBERSHIP # SECURITY CARD # START DATE DD MM YY NAME: FIRST LAST DATE DD MM YY OF BIRTH HOME ADDRESS HOME/CELL PHONE
More informationPersonal Training Initial Packet
Personal Training Initial Packet ****Please complete and return to the reception desk at least 2 days prior to your scheduled Fitness Assessment**** Name: D.O.B: Today s Date: Member or Non-member (circle
More informationPersonal Training Program Information and Policies
Personal Training Program Information and Policies Welcome to the Student Recreation Center s (SRC) Personal Training Program! We are delighted that you chose us as a part of your commitment to health
More informationMEDICAL INFORMATION: Physician s Name: Phone #: When was your last physical examination?:
PERSONAL INFORMATION: HEALTH STATUS QUESTIONNAIRE Name: Phone (hm): (bus): Address: City: State: Zip: Occupation: Male/Female: Age: Height: Weight: Lbs.: Emergency Contact: Phone: Relationship: MEDICAL
More informationWAIVER AND RELEASE FROM LIABILITY
COACHING CONTRACT I hereby contract Start-Tri.Com as my personal coach for endurance sports. I agree to pay for coaching services up front at the rate of $255/month for the Tier I package, $165/month for
More informationAutism Society of Greater Orlando s 2018 Autism Walk & Family Fun Day **Annual Fundraising Event**
Autism Society of Greater Orlando s 2018 Autism Walk & Family Fun Day **Annual Fundraising Event** The Autism Society of Greater Orlando is hosting its 13 th Annual Autism Walk & Family Fun Day inside
More informationName (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
More informationFORMS 1) PAR Q & YOU:
Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the Vanderbilt Recreation & Wellness Center (the Rec)
More informationCOST One on One.$60.00 per hour One on One..$30.00 per half hour Small Group $40/hour/person. Thank you for your interest in our program.
Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the Vanderbilt Recreation & Wellness Center (the Rec)
More informationENROLMENT FORM. Title: First Name: Surname: Postal Address: Postcode: Emergency Contact: Relationship: Phone: What is your main fitness goal?
ENROLMENT FORM Personal Information Title: First Name: Surname: Date of Birth: Sex: Female Male Postal Address: Postcode: Phone: Home: Work: Mobile: Email: Preferred method of contact: Letter Phone Email
More informationCWA SPONSORED FUNCTION
CWA SPONSORED FUNCTION REGISTRATION AND PERMISSION FORM AND RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT.... REGISTRATION PLEASE PRINT AND COMPLETE EACH ITEM IN FULL Registrant s Name: (separate
More information2017 FIT FOR LIFE: 6 Week Program Stay Fit Through The Holidays Fall 2017: October 30 th December 15 th
FOR YOUTH DEVELOPMENT FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY 2017 FIT FOR LIFE: 6 Week Program Stay Fit Through The Holidays Fall 2017: October 30 th December 15 th Application for Participation
More informationName Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
More informationPlease complete the medical history section below so that we can be sure to respond to any
200hr Yoga Teacher Training Application Please fill out this form and email it to teachertraining@ahamyoga.com with Teacher training application 2016 as the subject line. Any enrollments without this form
More informationGait Analysis Client Intake Form
Gait Analysis Client Intake Form Date: / / Welcome to the clinic! Please complete the following questionnaire. Your answers will help us better analyze your gait data. PERSONAL INFORMATION Name :_ last
More informationFor MWC Staff: Personal Information: Emergency Contact:
Masonic Wellness Center and Pool Member Application 361-5699 or ext. 33783 on campus Personal Information: Name: (Mr., Mrs., Ms.) (First) (Last) (MI) Birth Date: Phone: (H): (W): Address: E-mail Address
More informationADULT PRE-EXERCISE SCREENING TOOL
ADULT PRE-EXERCISE SCREENING TOOL This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. warranty of
More informationCompassionMassage.com. Client Intake Form
Name: Phone: ( CompassionMassage.com Client Intake Form ) E-Mail: Address: _ City: State: Zip: Date of Birth: Occupation: Referred by: In case of emergency: Phone: ( Chiropractor: ) General & Medical Information:
More informationPatient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
More informationDIOCESE OF CORPUS CHRISTI
Office of Youth Ministry DIOCESE OF CORPUS CHRISTI PO Box 2620 Corpus Christi, Texas 78403 (361) 882-6191 Fax (361) 693-6787 www.diocesecc.org/youth YouthOffice@diocesecc.org DIOCESAN CONFIRMATION RETREATS
More informationPersonal Training Packet
Personal Training Packet Personal Power Small Group Partner Personal Training Waiver Personal Training Policies All cancellations must be made 24 hours in advance of your appointment time. No-shows and/or
More informationRunner BOOTCAMP Registration Form
Runner BOOTCAMP Registration Form Registration for (Enter camp start date): Monday 6:15pm - Wednesdays 7:15pm - Saturday 8:15am (12 sessions) $160 Can come to all sessions for 4 consecutive weeks Payment
More informationCHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
More informationTalisman Therapeutic Riding, Inc. PO Box 300, Grasonville, MD
Volunteer Application (Page 1 of 6) General Information Form - Please Print Clearly and Complete Fully (Last Name) (First Name) (Middle Initial) (Nickname) Street Address: City: State: Zip Code: Home Phone:
More informationThank you for inquiring about our Shelly Aquatic Center at Brethren Village. We hope you will find the enclosed information helpful.
Thank you for inquiring about our Shelly Aquatic Center at Brethren Village. We hope you will find the enclosed information helpful. Non-Resident Enrollment Policy for use of Pool Non-Resident packet includes:
More informationCommunity Education. City State Zip Code. Term (please circle one) Summer 20 Fall 20 Winter 20 Spring 20
Student ID # 1651 Lexington Ave, Astoria, OR 97103 Community Education Today s Date: Bandit Community Fitness Bandit Community Fitness offers access to the College s weight room, cardio room and running
More informationRelease & Waiver Synergy Studio
Release & Waiver Synergy Studio I,, have enrolled in a program of physical activity, including but not limited to, body conditioning machinery used during the workouts offered by Synergy Studio. I affirm
More informationLOSE TO WIN CHALLENGE RULES, LIABILITY & PUBLICITY RELEASE
LOSE TO WIN CHALLENGE RULES, LIABILITY & PUBLICITY RELEASE CHALLENGE INFO: Participants will enjoy 8 weeks of unlimited access to the gym AND group fitness classes (Elite Group Training and Quick Fit classes),
More informationHEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
More informationCU Recreation Center
CU Recreation Center Personal Training Congratulations on your decision to invest in yourself! Our qualified, nationally certified personal trainers will provide you with the right information and right
More informationSocorro ISD Physical Packet Student Athlete Information Sheet (Clearly Print all information in Black or Blue Ink only.)
Socorro ISD Physical Packet Student Athlete Information Sheet (Clearly Print all information in Black or Blue Ink only.) School ID #: Grade: Graduation Date: Name: M ( ) F ( ) Date of Birth: Age: Home
More informationYoga as Healing Interest Form
Yoga as Healing Interest Form 1 Yoga as Healing Interest Form Mission and Goals The UC Davis CARE Program is excited to announce a new support service for survivors of sexual violence--yoga as Healing.
More informationWe look forward to helping you achieve your fitness goals!
Personal Training Congratulations on your decision to invest in yourself! Our qualified, nationally certified personal trainers will provide you with the right information and right training to help you
More informationDurham Public Schools Assumptions of Risk/Medical Treatment Release
Durham Public Schools Assumptions of Risk/Medical Treatment Release Student Athlete Name School Sport(s) Date The Durham Public Schools system makes every effort to prevent injuries, but injuries do occur
More informationNew Patient Information
New Patient Information First Name: Last Name: M.I.: Address: City: State: Zip Code: Mobile Phone: Home Phone: Email: Preferred method of communication: Mobile Phone Home Phone Email Date of Birth: Age:
More informationParticipant Information Exercise Equivalent Chart Weekly Activity Log Participation Agreement Waiver and Indemnity Agreement
Participant Information Email Exercise Equivalent Chart Weekly Activity Log Participation Agreement Waiver and Indemnity Agreement To: From: Wellness Representatives Jason Tucker Subject: Chairman s Fitness
More informationP: F: balance. Some exercise equipment will be used such as treadmills, NuSteps and resistance devices.
The Burke Rehabilitation Hospital recognizes the need to stay physically fit at all ages and functional levels. The Fit 4 Life After Stroke exercise program provides an exercise setting for people who
More informationNew Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
More informationPatient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
More informationPERSONAL TRAINING CLIENT INFORMATION PACKAGE
WEST VANCOUVER COMMUNITY CENTRE PERSONAL TRAINING PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means
More informationCASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
More informationThe University of Texas at Dallas Department of Recreational Sports Nutritional Guidance Registration Form
The University of Texas at Dallas Department of Recreational Sports Nutritional Guidance Registration Form Directions: Please, fill out as much information as possible. If you are unsure, leave that question
More informationTRANSFORM PARTNER CHALLENGE RULES, LIABILITY & PUBLICITY RELEASE
TRANSFORM PARTNER CHALLENGE RULES, LIABILITY & PUBLICITY RELEASE CHALLENGE INFO: Participants will enjoy 8 weeks full access to the gym and unlimited Elite Group Training, IQFit and QuickFit classes, as
More informationPhysical Activity Readiness Questionnaire
page 1 Health/Medical History Questionnaire This information is used solely as an aid and will not be released without your knowledge and consent. Name Date Birth date Address Street City State Zip Phone
More informationAPPLICATION INSTRUCTIONS
APPLICATION INSTRUCTIONS TEACHER TRAINING PROGRAMS Application Deadlines To process your application, please send your complete application no later than one week prior to the program start date. However,
More informationPersonal Training Initial Packet
Personal Training Initial Packet ****Please complete and return to the reception desk at least 2 days prior to your scheduled Fitness Assessment**** Name: D.O.B: Today s Date: Member or Non-member (circle
More informationPurpose: To inform all employees of the guidelines regarding the correct use of the Employee Gym.
Title: Gym Usage Policy Purpose: To inform all employees of the guidelines regarding the correct use of the Employee Gym. Scope: This policy applies to all employees who have use of the gym facility in
More informationOwlFit Personal Training Packet Thank you for making a commitment to your health and wellness through Personal Training! Our goal is to help educate
OwlFit Personal Training Packet Thank you for making a commitment to your health and wellness through Personal Training! Our goal is to help educate our patrons so that they may exercise safely and effectively
More informationTRANSFORM PARTNER CHALLENGE RULES, LIABILITY & PUBLICITY RELEASE
TRANSFORM PARTNER CHALLENGE RULES, LIABILITY & PUBLICITY RELEASE CHALLENGE INFO: Participants will enjoy 8 weeks of full access to the gym and unlimited Elite Group Training, IQFit and QuickFit classes,
More informationGET STARTED WITH US IN HEALTH & FITNESS
GET STARTED WITH US IN HEALTH & FITNESS 24-HOUR ACCESS RELEASE OF LIABILITY & ASSUMPTION OF RISK As a 24-hour secure-access fitness facility, PRAXIS Corporation dba BODYWORKS Health Fitness Rehabilitation
More informationRelease of Liability. Participant Signature: Participant Name (please print): Signature of Witness:
Release of Liability In consideration of being allowed to use NextEra Energy Health & Well-Being Fitness Center facilities and equipment, and being allowed to participate in fitness and wellness program
More informationBaa Hózhó Navajo Prep Math Summer Camp 2017
Math Summer Camp 2017 Application Packet Grades 7-12 May 30-June 3, 2017 Navajo Preparatory School, Farmington, NM Residential Camp Application Checklist A complete application must include the following:
More information