WEIGHT LOSS CHALLENGE: FACULTY AND STAFF Program overview: June 5th-August 2nd, 2018 The Faculty and Staff Weight Loss Challenge is an 8-week (16 session) program running from June 5th-August 2nd that will include exercise sessions on Tuesdays and Thursdays from 5:30-6:30 pm as well as wellness seminars on Wednesdays from 12:00-1:00 pm. Any employee seeking sustainable weight loss, community, and education about wellness is invited to join the program and start working toward their goals. For the exercise sessions, participants will be placed on teams that will be led by participants from last year s program who were successful in their weight loss. Team members will have the opportunity to work together to complete fitness challenges and compete with the other teams to win prizes and recognition. Participants will also have the unique opportunity to learn from a health and wellness coach about the nutrition aspect of weight loss and overall sustainable healthy living. This program is a great way for any staff or faculty member to get involved with a judgement-free group of like-minded individuals who will join together to pursue life-long health and well-being. Participation in this program comes with the unique opportunity to work with our highly qualified trainers and nutrition experts to jump start your weight loss goals and be a part of a community focused on health. To be eligible for the program you will need to have a BMI over 27 or above. If you are interested, please fill out this application and turn it in to the front desk by May 18th, 2018. We will then contact you based on this form if you will be eligible to participate in the program prior to accepting a payment. *There will be no meetings during the week of July 4 th *If you have already scheduled a vacation that is during this program, you may still join the program as long as you can come to at least 12 out of the 16 sessions.
Weight Loss Training Application Team captain: Name Last First MI Street Address City State Zip Phone Number Home Cell Email LUID# Affiliation: Undergraduate Graduate Doctorate Faculty/Staff Other Age: Date of Birth: Male Female Emergency Contact Information Name Phone Relationship Name Phone Relationship Medical History (past 6 months): by checking yes to any of these, Release Form required. YES NO 1) Are you aware, through your own experiences or a doctor s advice, of any reason (physical, mental, emotional) against your exercising without medical supervision? 2) Has a doctor ever said you have a heart condition and recommended only medically supervised activity? 3) Do you have chest pain brought on by physical activity? 4) Do you have a bone or joint problem that could be aggravated by proposed physical activity? 5) Do you have or have you had in the past, any of the following: a. Heart Condition b. Diabetes c. Uncontrolled Asthma d. Shortness of Breathe e. Arthritis f. Hernia g. Recent Surgery h. High Blood Pressure i. Knee Problems j. Back Problems k. Pregnant l. Pre-existing injuries
IF YES TO ANY OF THE PREVIOUSLY LISTED MEDICAL CONDITIONS, PLEASE EXPLAIN BELOW HISTORY/GOALS 1) Are you currently involved in a fitness program? If so, what are you doing? 2) What is your current height and weight? What is your desired weight? 3) How many times have you tried to lose weight in the past? 4) How would you rate your eating habits and understanding of nutrition as it relates to your goals? 5) Are you willing to commit to attending this program three times per week for the duration of the ten week? Does your schedule allow for you to participate? 6) Why would you like to be accepted into the Weight Loss Training Program? How would being involved in this program benefit you? I agree that this information is accurate and correct. I have filled this form in its entirety and understand that I do not hold Liberty University responsible for any inaccurate information given on this form: Signed: Date:
Fitness Assessment Medical Release Form: Only those checking yes to any of the Medical History section of this form are in need of this form to be completed. is medically free to participate in weight (Please Print Name) training, aerobic conditioning, and similar activities anticipated in the health club environment at Liberty University LaHaye Student Center. This Patient is free to participate without restrictions This Patient is free to participate with the following minor restrictions: Maximum Target Heart Rate: Physician s Signature Date Physician s Address Physician s Phone Number Note: This section is to be completed by the Liberty University SCD/ADF ONLY SCD/ADF Signature Release Date: Notes:
RELEASE, INDEMNIFICATION AND ASSUMPTION OF RISKS AGREEMENT TO BE SIGNED BY ALL ADULT PARTICIPANTS Welcome to Liberty University s Personal Training Program. The Personal Training Program (hereinafter the Training Program ) provides several types of training, including methods often referred to as cardio-training, weight-training, and functional-training. These services are provided both in the LaHaye Recreation and Fitness Center and at other locations, as necessary or appropriate for your particular needs (the LaHaye Recreation and Fitness Center and all other locations used for training, whether within or outside of the LaHaye Recreation and Fitness Center building, are referred to herein collectively as the Fitness Center ). Before you may participate in any activities provided by the Training Program, including Personal Training services, you must read and promise to be bound by the following terms of this agreement. This agreement is legally binding upon you and contains important waivers of certain rights you may have. Accordingly, you should thoroughly read each of the provisions of this agreement and understand the entire agreement before you sign your name below. 1. Notification of Risks Participation in the Training Program, and entry into the Fitness Center, which includes all equipment, and all surrounding areas and supporting structures, and participation in any other activities and programs within the Fitness Center, will expose you to risks of injury or even death. The activities and programs offered by the Training Program and/or occurring within the Fitness Center are inherently dangerous in their nature and may be ultra-hazardous to your health. The recreational activities provided by the Training Program and occurring in the Fitness Center, including without limitation, all types of exercise (whether aerobic or non-aerobic), weight-lifting, stretching, and all other activities that may occur as part of your personal training program and/or within the Fitness Center, are HAZARDOUS and expose you to risks that may result in your injury, illness, or death. These risks include, but are not limited to (i) unpredictable reactions of your respiratory, cardiovascular, and musculoskeletal systems, physical exertion or over-exertion, the possibility that while safe for others, a particular activity or program is not safe for you personally, the design and condition of the weight and fitness equipment and related structures, difficulty using the fitness equipment, loss of control of weights or other equipment, falling, and collisions with staff, other participants, or spectators (whether moving or stationary) (ii) similar risks resulting from the use by others of the fitness equipment or fitness center. You are not protected from all features or objects within the Fitness Center that could injure you as a result of your collision with these features or objects. Certain structures or features within the Fitness Center may be padded. Your collision with any padded object may still result in your injury or death. You are also exposed to risks from failures of your own equipment, or failures of equipment belonging to or used by other participants in the Fitness Center. Ordinary use of Fitness Center equipment and participation in the Training Program or other Fitness Center activities and programs can result in cosmetic or more serious injuries such as scraping, scratching, blistering, or puncture of the skin and other organs, dehydration, exposure to infectious diseases, injuries to the musculoskeletal system, such as cramping, tearing, ripping, or breaking of muscles, tendons, ligaments, or bones, and problems affecting your respiratory, cardiovascular, and other bodily systems, all of which may result in other serious conditions such as paralysis, stroke, and heart attacks, among many others. All of the foregoing risks can result in your serious physical injury, illness, permanent disability, or even death. Injuries are a common and ordinary occurrence to those who participate in the types of activities and programs provided by the Training Program and/or in the Fitness Center.
You acknowledge all of the foregoing risks, and that it is impossible to anticipate all of the risks inherent in these types of activities and programs. If you find that any condition of the Training Program or the Fitness Center is unacceptable to you, you agree to notify a Fitness Center employee immediately and leave the Fitness Center. 2. Assumption of Risks In spite of the risks involved in entering the Fitness Center and in participating in the activities and programs provided by the Training Program and/or occurring within the Fitness Center, and in consideration of being allowed to participate in those activities and/or programs, YOU FREELY AND VOLUNTARILY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY OR DEATH that may result from your participation in any activities and/or programs provided by the Training Program and/or occurring within the Fitness Center. 3. Release and Waiver of Claims Given the risks associated with your participation in the activities and programs provided by the Training Program and/or occurring within the Fitness Center and your assumption of those risks, you hereby agree to release and to waive your rights to recover against, and to indemnify, defend and hold harmless Liberty University, Inc. (referred to herein as Liberty University ), and all of its officers, directors, employees, agents, servants and insurers, from and for any and all damages, losses, claims, causes of action, suits, demands, costs, complaints, including those resulting from your illness, injury, and/or death, (i) arising as a result of, or relating to your participation in the activities and/or programs provided by the Training Program and/or occurring within the Fitness Center, (ii) occurring during any time you are on the property of Liberty University, and/or (iii) occurring while you are being transported for medical care or receiving medical care in accordance with section numbered 6 below. Your obligations under this paragraph shall not be limited or reduced in any way because any of the damages, losses, claims, causes of action, suits, demands, complaints, including those resulting from your illness, injury, and/or death, arise or result, in whole or in part, from the negligence of, or breach of any express or implied warranty or duty by Liberty University, or any of its officers, directors, employees, agents, servants and insurers. 4. Covenant Not To Sue You promise and agree that you will not sue Liberty University, or any of its officers, directors, employees, agents, servants and insurers for any damages, losses, claims, causes of action, suits, demands, costs, complaints, including those resulting from your illness, injury, and/or death, released and waived by you in the preceding paragraph. You further agree that Liberty University may plead this agreement as a full and complete defense to any suit brought in violation of this promise. 5. Indemnification Given your acknowledgment of the risks associated with your entry into the Fitness Center and/or your participation in the activities and/or programs provided by the Training Program and/or occurring within the Fitness Center, you hereby agree to indemnify, defend, and hold harmless Liberty University, and all of its respective officers, directors, employees, agents, servants and insurers, from and for any and all damages, losses, claims, causes of action, suits, demands, costs (including attorney s and opinion witness fees), and complaints, arising as a result of or relating to, any of your actions or omissions, or which you may otherwise cause, in whole or in part. 6. Medical Treatment You authorize Liberty University and/or its personnel to seek medical attention or care on your behalf or to transport you or cause you to be transported to a medical facility or hospital. However, you agree that Liberty University has no obligation to seek or provide such medical care to you. In the event Liberty University seeks transportation and/or medical care on your behalf, you agree to pay all charges related to such transportation and/or medical care. You further agree to indemnify and hold harmless Liberty University from all such charges. 7. Responsibility to Advise Staff of Health Conditions. You agree to advise Training Program staff and every personal trainer with whom you work of any and all physical and/or health related conditions you have which may affect your ability to participate safely in Training Program activities or programs of any type. You agree to consult your own physician before participating in any Training Program or Fitness Center activities or programs to be certain that you are aware of any physical or medical condition of your own which may add to the risk of
illness, injury, or death as a result of your participation in such activities and programs. If requested by Training Program staff, you agree to obtain your own physician s written approval for you to participate in such activities and programs. 8. Equipment Recommended by Your Physician You agree to obtain (at your own expense) and use, without the necessity of any reminder to do so by Training Program staff, any and all equipment which your physician directs or recommends for you when participating in any programs or activities provided by or occurring in the Fitness Center. 9. Your Responsibility to Communicate You recognize and agree that while participating in Training Program activities or programs you may experience symptoms of physical or medical problems which are not evident to Training Program staff or others, including but not limited to pain, nausea, dizziness, feeling faint or light-headed, or any other discomfort, and you agree that if you do, you will stop your participation immediately and alert Training Program staff of your symptoms. You further acknowledge and agree that as part of many activities and programs it is appropriate for Training Program staff to urge and push you to exert yourself physically more than you are or have been exerting yourself, in order to help you improve your fitness and/or excel in your activity or program. You also acknowledge and agree that you have the right to stop or reduce your level of exertion at any time (whether being urged to continue or not), and that you will do so immediately if you become uncomfortable in any way, or if you have any concern about whether you should continue, and you will advise Training Program staff of your discomfort or concern immediately. 10. Agreement for Physical Contact You acknowledge and agree that the activities and programs provided by the Training Program often require physical contact between you and Training Program staff in order to demonstrate proper procedures and techniques, to ensure that your body movements are correct, to demonstrate proper use of equipment, and for various other reasons. You also agree that if you believe such contact is unreasonable, inappropriate, or unnecessary, you will demand that such contact cease immediately, and immediately advise Training Program staff, including the manager on duty at the time of the contact, of your belief and the reasons for such belief. 11. Personal Equipment In the event you bring any equipment or personal property into the Fitness Center, you agree to assume all risks associated with the use of such equipment or property. You agree Liberty University is not responsible for any loss or theft of, or damage to any equipment or personal property you bring into the Fitness Center. 12. Severability / Modification In the event any section or sections of this agreement is (are) found to be unenforceable, you agree the remaining sections shall remain enforceable and fully binding upon you. This agreement may only be modified in a writing signed by an officer of Liberty University. Any alleged verbal modification of your obligations resulting from this agreement is void. The use of the term and/or herein shall be construed to impose the greater obligation upon you. 13. Binding on Successors Each of your promises and agreements contained herein is binding on your assignees, subrogors, distributees, family members, heirs, next-of-kin, executors, personal representatives, administrators and successors of every kind. 14. Forum for Disputes You agree that any and all disputes between you, and Liberty University or its officers, directors, employees, agents, servants and insurers arising from your entry into the Fitness Center or your participation in the Training Program or other activities within the Fitness Center, including your illness, injury, or death, or any dispute regarding this agreement will be governed by the Laws of the Commonwealth of Virginia, notwithstanding its choice of laws provisions. You further consent to the exclusive jurisdiction of the Virginia State Courts. You agree that the venue for any such dispute between you, and Liberty University will be in the state court located in Campbell County, Virginia and that you waive your right to a trial by jury. 15. Duration of Promises - You agree the promises and agreements you make in this agreement are binding upon you forever, which includes any time you enter into the Fitness Center or participate in the Training Program or any other activities within the Fitness Center in the future.
16. Behavior at Facility You agree to read and abide by all posted signs at the Fitness Center and to comply with all instructions given to you by Fitness Center staff, as well as the Training Program and Fitness Center Policies and Procedures Manual, which is available at the front desk and on the Liberty University website. You agree you will not engage in any reckless behavior, as determined by Training Program or Fitness Center staff, while in the Fitness Center. Persons under the influence of drugs or alcohol are not permitted in the Fitness Center or otherwise allowed to participate in Training Program activities. You agree your failure to comply with the requirements of this paragraph may result in your removal from the facility without refund. 17. Accident Investigation In the event you witness or are involved in an accident or event resulting in property damage or personal injury of any kind, no matter how insignificant it may seem, you agree to immediately report such accident or event to a Training Program or Fitness Center employee and to cooperate in the investigation of the accident or event. 18. Use of Names and Images By signing this form and entering into the Fitness Center you hereby consent to Liberty University s (and its affiliate s) use of your name, portrait and/or picture for advertising or for purposes of trade. BY SIGNING BELOW YOU AGREE YOU HAVE CAREFULLY READ AND UNDERSTAND ALL OF THE TERMS ABOVE. (SEAL)[printed name of participant referred to above as You or you ] [signed name of participant] [participant s date of birth] [date of signature]
Weight Loss Training Program PACKAGE: 8 Weeks: 16 training sessions 8 Wellness seminars PAYMENT: Cash Credit Card Check *$30 fee for all returned checks Personal Training Contractual Agreement Agreement Policies: I understand that by signing this agreement, I will abide by and follow the policies held by Liberty University s LaHaye Recreation and Fitness Center, which are stated in this agreement. Int. There will be no refund for this purchase after the first 24 hours. If a portion of the package is used within the 24 hour period, the refund will be pro-rated based on the number of sessions used. One session is 50 minutes long in length. I understand and agree upon signing this agreement, that if I am late, the time will be taken out of the 50 minute session. I also understand that if there is need for a cancellation, I will not be refunded for the individual sessions nor will I be able to make the session up. Int. This program is only active during the weeks advertised. I understand that my sessions are not transferable to any other individual and are exclusively for my use only. Int. I also agree that by signing this document, I will not hold Liberty University or it s subsequential departments responsible for results desired whether they are attained or not. Payment is not refundable based on results received from the personal training package. Int. By signing this document I have read and agree to the above: Signature: Date:
PARTICIPATION CONTRACT OF PROGRAM POLICIES TO BE SIGNED BY ALL PARTICIPANTS I. Attendance and Late Policy Participants are expected to be in attendance at the majority of both fitness and nutrition sessions. If for any reason a participant is unable to attend any session, he or she is expected to notify their trainer (for fitness sessions) and the dietician (for nutrition sessions) with a minimum 24-hour notice via email. Participants are also expected to be in the designated meeting area at or before the scheduled meeting time. Punctuality and attendance are highly valued in this program and failure to share this value will result in penalties for the participant s team. Specific personal situations and illnesses should be discussed on an individual basis. II. Dress Code Policy Participants are expected to arrive at each fitness session in proper exercise attire which includes shorts or athletic pants, an appropriate loosefitting tee shirt or athletic top, socks, and sneakers with laces and support. Failure to dress in proper athletic wear could result in serious injury or heat-related illness. Participants are expected to provide their own source of water or sports drink and arrive with their drinks prepared. Questions about proper pre and post-exercise hydration should be discussed with the dietician. III. Attitude Policy Participants are expected to be respectful to the certified trainers and dietician. There is a no tolerance policy for negative attitudes and consistent complaining due to the effects that it has on other participants. If there are any specific concerns about program operations, they should be discussed individually with the trainers or dietician. A positive attitude and overall willingness to work will significantly increase weight loss success. Signing this form indicates that you have read and understood the program policies outlined above: Signature: