The University of Texas at Dallas Department of Recreational Sports Nutritional Guidance Registration Form

Transcription

1 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 blank. Name: Phone Number: Address: Time Preference: Date of Birth: Who Referred You: Nutritional Training Sessions Current Personal Training Non PT Client Client Single Session (general plan) $15 $25 1 day customized meal plan $25 $35 3 day customized meal plan $50 $60 7 day customized meal plan $75 $85 *12 week transformation plan $300 $350 *12 week transformation includes customized meal plan, follow up consultations, weekly food log review and 2 personal training sessions per week All payments must be received prior to the scheduling of your nutritional training session(s). Please note that the following policy will be enforced for all nutritional training sessions: There will be a 24-hour cancellation policy on all sessions. If the client does not cancel within 24 hours the session will be void and no refund will be given. Participation in all activities in the UTD Activity Center, sponsored by the Department of Recreational Sports, is voluntary on behalf of all participants. Participants acknowledge and agree that the University of Texas at Dallas does not provide insurance for any of its activities and shall not be liable for any injuries that occur at this location or any of it programs. Participants Signature For office use only Date Payment Method (Circle) Cash Check Credit Card Receipt number: Employee name: Pre-screening Interview Date By Client Accepted Denied Trainer Family Medical History Please list the family members affected, the age of onset, type and the action taken for the following ailments: Heart Disease Yes No High Blood Pressure Yes No

2 Elevated Cholesterol Yes No Diabetes Yes No Cancer Yes No Stroke Yes No Obesity Yes No Please provide any additional comments below:

3 Nutritional Evaluation and Program Participation I have volunteered to participate in a program of progressive physical exercise. I waive any possibility of personal damage which may be blamed upon such a program in the future and accept the responsibility for accepting such exercise and assistance. The possibility of certain unusual changes during exercise does exist, including abnormal blood pressure, fainting, disorders of heart beat, and very rare instances of heart attacks. Every effort will be made to minimize such changes by preliminary examination and observation during situations which may arise. I herby acknowledge and accept these which would preclude an exercise program. Participant s signature: Date: An examination by a physician should be obtained by all participants prior to involvement in an nutritional program. If a participant refuses to obtain a physician s consent, he/she must sign the following statement: I,, have been informed of the need for a physician s approval for participation in a progressive nutritional and fitness program. I fully understand the strenuous nature of the program and accept complete responsibility for my health and understand that no responsibility is assumed by the leaders of the program or sponsoring agency. Participant s signature: Date: has medical approval to participate in an nutritional and fitness program which will include progressively increasing amounts of general conditioning exercises. I certify that the person whose name appears above is free from infectious disease and that there appears to be no reason why such an exercise program should not be undertaken. Physician s signature: Date: Participation in all activities in the UTD Activity Center, sponsored by the Department of Recreational Sports, is voluntary on behalf of all participants. Participants acknowledge and agree that the University of Texas at Dallas does not provide insurance for any of its activities and shall not be liable for any injuries that occur at this location or any of it programs.

4 The University of Texas at Dallas Recreational Sports Nutritional Guidance Information Sheet Congratulations on your first step to a healthier lifestyle. Below are some facts that you will need to be aware of prior to your nutritional sessions: There will be a 24-hour cancellation policy on all sessions. If the client does not cancel within 24 hours the session will be void and no refund will be given. You will receive a call from your nutritionist within 48 hours of registration, unless you register during weekend hours (Friday afternoon to Sunday evening) or holidays. If this is the case, you should expect the phone call the next business day. The day of your session, you should not exercise or drink coffee, and plenty of water should be consumed throughout the day. Wear comfortable clothing the day of your session. One of the tests is body fat testing, therefore the trainer will need access to the thigh, triceps, hip, and midriff. A water bottle is optional but highly recommended for all sessions. Backpacks and personal belongings are not advised in the fitness center; therefore it is recommended that all clients purchase a locker to store items or use the daily use lockers. If at any time you have any questions, please feel free to contact Holly Worrell at Thank you for participating in our nutritional guidance program. We hope you get a great workout and we have a positive impact on your healthy lifestyle. Informed Consent for Nutrition & Personal Training

5 The University of Texas at Dallas Student Activity Center I agree to voluntarily participate in a Nutritional/Personal Training program in the attempt to improve diet, health and physical fitness. I understand that the purpose of this program is to accomplish goals set by myself with a specific program based on needs, interests, and recommendations by certified Nutritionist or certified Personal Trainer. Furthermore, I understand that the recommendation made are no more than recommendations, and will or have consulted a doctor concerning such recommendations before attempting any training program. The reaction of the cardio-respiratory and skeletal/muscle systems cannot be predicted with complete accuracy. All personal training programs will include a warm up, strength training and/or cardio-respiratory conditioning at a target heart rate or equivalent perceived exertions, and a proper cool down period. I understand that I am responsible for monitoring my own condition throughout the exercise program and will cease any activity and inform the trainer of any unusual symptoms. If requested by certified personal trainer I may be required to ring a physician s approval and/or recommendations before starting any program. I certify that I am in good health and if at any time these conditions change I will notify the personal training staff. It is expressly agreed that all use of the UTD fitness equipment and/or facilities shall be undertaken by a guest at his/her own risk, and any corporate entity and/or the UTD fitness facility shall not be liable for any injuries or any damage to any guest or the property of any guest whatsoever, including, without any limitations, those damages resulting in acts of passive or active negligence on the part of and corporate entity and/or the UTD fitness facility. The participant, for himself/herself and on behalf of his/her executors, administrators, heirs, assigns, and successors, does hereby expressly forever release and discharge any corporate entity, the State of Texas, The University of Texas System, the University of Texas at Dallas, the UTD fitness facility, its officers, employees, and successors from al such claim, demands, injuries, damages, actions, of causes of action. Any corporate entity and/or the UTD fitness facility shall not be responsible or liable to guest for articles damaged, lost or stolen in or about any corporate entity and/or the UTD fitness facility or from lockers, or for loss or damages to any property including but not limited to automobile and contents thereof. In signing the consent from, I affirm that I have read this form in its entirety and that I understand the nature of the program (Nutrition/Personal Training). I also affirm that my questions regarding the programs have been answered to my satisfaction. Participant s signature Date The University of Texas at Dallas

6 Nutritional Training/Guidance Agreement Name: Address: Phone: (H) (C) Nutritionist: Sold By (employee): Note: Copy of Receipt: Date Time Member s Signature Nutritionist Signature Terms of Agreement 1. Members and trainer must sign for each session upon completion thereof for confirmation of service 2. Cancellation require a 24-hour notice, if notice is not given member will be charged for missed session 3. Refunds are given for medical reason only 4. Problems or concerns should be addressed to Holly Worrell Member Signature: Trainer s Signature: Total # Sessions: Price per Session Date: Expiration Date: Total Price$ Payment Method Total Paid$ Date: / / Amount Due $ Date: / / Amount Due$ Date: / / Member Signature of Receipt

7 Learn how to reach your goals, how to eat for optimal performance, how to energize your workouts and how to build muscle strength. Sessions are designed to meet the specific nutrient needs of each client and include computer generated nutritional analysis for your specific needs. Counseling will begin with a completion of a 3 day food diary. You will then meet again with the trainer to identify your goals for dietary improvement. A diet analysis can provide useful information for everyone: Find out how your food choices compare with the recommended intakes for protein, carbohydrates, fats and vitamins. Learn how many calories are right for you at your current weight and activity level. Get some tips for healthy and smart dietary changes Get customized meal plans that take into consideration some of your favorite foods. General food plan-will provide you with the USDA s recommended food summary for your age and weight. Gives a general guide of the different types of foods such as grains, fats, proteins, etc so that you can build a healthy meal plan to use for your recommended daily allowances. Also includes a review of your 3 day food journal with some healthy tips and alternatives. 1 session for personal training clients-$15 1 Session for non clients-$25 Customized food plan-includes the items from the general meal plan as well as a customized written meal plan using some of the foods you enjoy. This plan can be tailored to meet your goals whether they are fat loss, muscle gain or a desire to maintain your current health level. It will provide you with your daily recommended calorie intake for your desired goals and a breakdown of specific details for protein, carbohydrate and fat consumption. During the first session, you will sit down with the counselor and discuss what you currently eat and like so that meal plans can be written specifically for you. Will also include a shopping list once the meal plans have been written. Personal Training Client Non-Client 1 day customized meal plan- $25 $35 3 day customized meal plan- $50 $60 7 day customized meal plan- $75 $85 12 week transformation package (includes customized meal plan, follow up consultations, weekly food log review and 2 personal training sessions per week.) o Great for after holiday s o Getting ready for spring break swimsuit season o Personal Training Clients-$300 o Non-Client-$350 *3 day and 7 day include a follow up session and a review of your food log for 2 weeks. Nutritional Training Food Record

8 Name: Age: Sex: D.OB. Address: City: State: Zip: Phone: Best time(s) to meet: Height: ft. in. Weight: Desired weight: Activity: Light/Moderate/Heavy What type: How often: Are you Diabetic:Yes No Are you Pregnant:Yes No Are you Breastfeeding: Yes No Special concerens (i.e. weight loss/gain, health concerns, nutrient deficiency, cholesterol, fiber, etc.): Instructions: 1. Record EVERYTHING you eat and drink for 3 days. It is best to use two week days and one weekend day; record as soon after you eat as possible. 2. When describing a food, be specific and precise (i.e. brand name, cooked, raw, fresh, frozen, canned, chopped, whole wheat, low fat, non fat). 3. When recording amounts, use standard measures (i.e. cups, tablespoons, teaspoons, number of pieces). Date Time Food/Description Amount