Personal Training Request

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Please correct the field(s) marked in red below:

Contact Information:

Contact Information:

Emergency Contact:

Emergency Contact:
Number of personal training session per week:
Number of personal training session per week:
Preferred Start Date
Length of Each Session
Length of Each Session
Type of Training:
Type of Training:

Preferred day(s) to train (Please check all that apply):

Preferred day(s) to train (Please check all that apply):
Time(s) of the day you are available for training:
Time(s) of the day you are available for training:
Trainer Preference
Trainer Preference
Specific Trainer Request
Specific Trainer Request

Please indicate your primary fitness goals:

Please indicate your primary fitness goals:

What is your present level of physical activity?

What is your present level of physical activity?

Medical History

Please indicate any present or past history of the following medical conditions by checking YES or NO. 

History of heart attack or surgery, chest pain?

History of heart attack or surgery, chest pain?

Abnormal EKG or irregular heartbeat?

Abnormal EKG or irregular heartbeat?
Osteoporosis or osteopenia?
Osteoporosis or osteopenia?

Limitations or mobility restrictions?

Limitations or mobility restrictions?
Pregnancy or recent birth?
Pregnancy or recent birth?
High Blood Pressure?
High Blood Pressure?
Stroke?
Stroke?
Unexplained dizziness or fainting?
Unexplained dizziness or fainting?

Surgery?

Surgery?

Joint replacement?

Joint replacement?
Breathing or lung problems?
Breathing or lung problems?
Muscle, joint or back pain?
Muscle, joint or back pain?
Hernia or condition that limits training?
Hernia or condition that limits training?
Smoke or quit within past 6 months?
Smoke or quit within past 6 months?
Pain or swelling in the legs?
Pain or swelling in the legs?
Circulatory problems?
Circulatory problems?
Circulatory problems?
Circulatory problems?
Diabetes?
Diabetes?
Other
If you answered YES to any of the above questions, please provide additional information below:
Do you have any restrictions?
Please list any other medical conditions:
If yes to the above, has your doctor approved your participation in personal training?
If yes to the above, has your doctor approved your participation in personal training?
Please list any medications you take:

Assumption of risk:
I understand that participation in any physical activity involves inherent risks, and that even
when safety precautions are utilized, injuries can occur. I fully agree to assume all risks
when following the fitness program and exercises prescribed by Ida Lee Recreation Center
and its trainers, and agree to hold them harmless in the event such injury occurs. If I
experience unusual pain or discomfort during participation in any activity, I will inform
the trainer immediately. I am aware that personal health/accident insurance is my responsibility.
I claim that to the best of my knowledge, I do not have any medical issue that will prohibit
my safe participation in this exercise program. 

Refund Policy

  • All individual sessions and packages are non-refundable and non-transferable.  Modifications to training packages are not permitted.
  • Sessions are good for 1 year from the date of purchase.  Any remaining training sessions after expiration date will be forfeited with no refund available.
  • You must notify your trainer 24 hours in advance of cancellations.  If you fail to give 24 hours notice, you will be charged for your full session.
  • Regardless of the arrival time, session will end at the scheduled time.
  • Trainers may not be available immediately.  You will be contacted within 1 week of your personal training request.
  • For documented long-term illness or injury, a refund may be considered.


By hitting the "submit" button below, you agree to the assumption of risk and refund policies.

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