MEMBER PERSONAL TRAINING PACKET

Transcription

1 Dear YMCA Member, MEMBER PERSONAL TRAINING PACKET Congratulations on the decision to improve your health and well-being and work with one of our nationally certified personal trainers! THIS ENTIRE PACKET MUST BE COMPLETED AND RETURNED TO THE ALEXANDER FAMILY YMCA BEFORE AN APPOINTMENT CAN BE SCHEDULED. Once all paperwork is received, YMCA staff will contact all personal trainers and a trainer whose availability matches yours will contact you to set up your first appointment. Based on your health/exercise history, a medical clearance from your physician may be required prior to exercise. At the time of payment, a PT Session Log will be created and given to your trainer as receipt of payment. No sessions may be completed until payment has been made. INDIVIDUAL PERSONAL TRAINING RATES $56.00 (1) 1-hour session $ (5) 1-hour sessions $ (10) 1-hour sessions TANDEM PERSONAL TRAINING RATES (PRICE INDICATES PER PERSON) $39.00 (1) 1-hour session $176 (5) 1-hour sessions $331 (10) 1-hour sessions SESSION CANCELLATION POLICY Cancellations must be made with your trainer at least 24 hours in advance. All cancellations (or no shows) made less than the 24 hours in advance of session will result in a loss of that scheduled session and counted as a session used. USAGE AND REFUND POLICY All Personal Training sessions and/or packages must be completed within 6 months of the purchase date. A $50 cancellation fee will apply to all cancelled packages. A full refund will only be given if the client provides a doctor s note due to an injury OR if he/she is moving out of the Triangle area and therefore cancelling membership. If a client is unhappy for any reason with his/her trainer, arrangements will be made to identify another personal trainer. For additional questions, contact Rodney Alexander at Rodney.Alexander@ymcatriangle.org 1

2 I desire to engage voluntarily in the Alexander Family YMCA exercise program in order to attempt to improve my physical fitness. I understand that the activities are designed to place a gradually increasing workload on the cardiorespiratory and musculoskeletal systems and thereby attempt to improve their function. The reaction of these systems to such activities cannot be predicted with complete accuracy. There is a risk of certain changes that might occur during or following exercise, including but not limited to, abnormalities of blood pressure and heart rate. I understand that the fitness-testing program is designed to evaluate cardiorespiratory fitness, body composition, flexibility, and muscular strength and endurance. These tests may include, but not limited to, sub-maximal cardiorespiratory tests to predict aerobic capacity, circumference measurements to estimate body composition, static stretches to observe flexibility, and sub-maximal resistance to examine muscle strength and endurance. I understand that the purpose of a regular exercise program is to improve and maintain cardiorespiratory fitness, body composition, flexibility, and muscular strength and endurance. A specific exercise plan will be designed for me, based on my needs, interests and any recommendations provided by my physician. I understand that I am responsible for monitoring my own condition throughout the exercise program and should any unusual symptoms occur, I agree to cease active participation immediately and inform the trainer of my symptoms. In the event that medical clearance must be obtained prior to my participation, I agree to consult my physician and obtain written clearance or allow the YMCA to obtain such clearance. Also, in consideration for being allowed to participate in the YMCA exercise program, I agree to assume the risk of such exercise, and further agree to hold harmless the YMCA and its staff members conducting the exercise program from any and all claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims that may result from injury or death, accidental or otherwise, during or arising in any way from, the exercise program. In signing this consent form, I affirm that I have read this form in its entirety and understand the nature of the YMCA Personal Training policies, fitness testing and exercise program. I also affirm that my questions regarding the program have been answered to my satisfaction. Signature of participant Date Parent/Guardian Signature (if under 18 years of age) Date 2

3 NAME _ AGE PHONE (H) (C) EMERGENCY CONTACT PHONE PHYSICIAN PHONE CURRENT HEIGHT PLEASE CHECK ALL THAT APPLY: Heart attack Heart failure Congenital heart disease Heart valve disease Cardiac catherization Coronary angioplasty Pacemaker Implantable cardiac defibrillator Heart transplantation CURRENT WEIGHT Other heart surgery Heart murmur Stroke Diabetes Epilepsy Fibromyalgia Emphysema Chronic Bronchitis Osteoporosis Pregnant You experience chest discomfort with exertion You experience unreasonable breathlessness You experience dizziness, fainting, or blackouts You experience unexplained heart palpitations/rhythms Note: If you marked any of the above statements, your physician will need to submit a doctor s not permitting you to exercise before you can start your exercise program at the Alexander Family YMCA. Cardiovascular risk factors: You smoke You are physically inactive You are a man older than 45 years You are a woman older than 55 years or you have had a hysterectomy or you are post menopausal Blood pressure is > 140/90, you take blood pressure medication, or you don t know your blood pressure Cholesterol level is > 240 mg/dl, use cholesterol lowering medication, or cholesterol level is unknown Close blood relative had a heart attack before age 55 (father or brother) or age 65 (mother or sister) Note: If you marked 2 or more of the statements in this section, your physician will need to submit a doctor s not permitting you before you can start your exercise program at the Alexander Family YMCA. Musculoskeletal risk factors: Head/Neck Injury Shoulder/Clavicle Injury Upper Back Injury Lower Back Pain Arm/Elbow Injury Wrist/Hand Injury Hip/Pelvic Injury Knee/Thigh Injury Ankle/Foot injury Bone Fracture Arthritis Calcium Deposits Nerve Damage Tennis Elbow Other (Specify) 3

4 List any current medications and its purpose: List any other concerns regarding your ability to exercise safely: Describe your current exercise/physical activity: Please indicate your fitness goals: Increase strength Improve cardiovascular fitness Reduce body fat Exercise regularly Sports conditioning Improve flexibility Improve muscle tone Increase muscle mass Injury rehabilitation Other (Specify): 4

5 PERSONAL TRAINING PREFERENCES We are committed to accommodating your requests and preferences below. Please be as specific as possible. This allows us easier allocation of the correct trainer based on your needs. Name: Phone: I am interested in (select one): One Personal Training session 5 Personal Training sessions 10+ or long-term Personal Training If long term, how many days per week? I prefer (select one): Female trainer Male trainer No preference If you have the name of a trainer you would like to request, please indicate here: _ I would like to focus on (select one): Land exercise Water exercise Combination of water & land exercise I am available for training: M T W TH F S Sun (circle all that apply) All hours available to train: _ (please specify hours) 5