Personal Training Intake Form

Name

Date of Birth

mm/dd/yyyy

Address

Phone Number

Phone

Emergency Contact Name

What is your primary goal(s)?

Are you currently exercising regularly?

Yes

How much time are you willing to commit to an exercise program?

What types of exercise interest you?

Are you currently taking any medications? (if so please list)

Cancellation and Refund Policy

If the student cancels more than 24 hours before the lesson, he or she will have the opportunity to reschedule the personal training session and will not be charged. If a private training session is cancelled within 24 hours, or a student does not arrive for the lesson within 15 minutes of the start time, the session will still be charged.

I read, understand, and agree with the Cancellation and Refund Policy

Signature of Participant:

Parent/Guardian Signature (if under the age of 16):

Date

mm/dd/yyyy

PAR-Q: Physical Activity Readiness Questionnaire

For most people, physical activity should not pose any problem or hazard. The physical activity readiness questionnaire has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide when you answer these questions.

Please read the questions carefully and answer each one honestly:

Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?

Yes

Do you feel pain in your chest when you do physical activity?

Yes

In the past month, have you had chest pain when you were not doing physical activity?

Yes

Do you lose your balance because of dizziness, or do you ever lose consciousness (during activity)?

Yes

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

Do you know of ANY OTHER REASON why you should not do physical activity?

Yes

If you answered YES to one or more questions, please speak with your doctor and have them fill out a Medical Clearance form BEFORE you participate in a personal fitness training session.

Acknowledgment of Risk and Waiver of Liability

As a condition of use of any City of Boulder Parks and Recreation facility or participation in any program, sports league, class, recreation or fitness activity, you agree as a participant or parent/ guardian of a participant in the program, to assume all risks and hazards of engaging in or as a spectator at any city activity or facility, including assuming all risks for personal injury, death and property damage.

You further agree to hold harmless the City of Boulder, its staff, instructors, volunteers, officials, sponsors, partners or representatives from liability for any losses, damages or injuries that may occur in any way as a result of these activities or facility uses – regardless of cause.

You further certify that you are properly prepared to engage in any activities you have selected and that you have recently consulted a physician to establish that it is safe and appropriate for you to engage in these activities.

Participants (or the parents/guardians of minor children) may also be required to complete a medical health history and/ or sign an additional waiver of liability before participation in any programs or classes. Anyone recovering from an injury or illness must first discuss their return to physical activity with their physician and Parks and Recreation instructor before enrolling/participating.

You further agree that there is risk associated in regard to the COVID-19 pandemic and possible exposure.

Therefore, having read and understood this waiver and in consideration of your accepting my entry into a City of Boulder recreation facility or program, I, for myself and anyone entitled to act on my behalf, waive and release the City of Boulder, all staff, volunteers, sponsors, and representatives from all claims or liabilities of any kind arising out of my participation in (or as a spectator of) any program or use of any facility.

NOTE: If a facility user or program participant is under 18 years of age, you as a parent or legal guardian, agrees to the same terms, conditions and waiver of liability set forth in this agreement.

I read, understand, and agree with the Acknowledgment of Risk and Waiver of Liability.

Signature of Participant:

Parent/Guardian Signature (if under the age of 16):

Date

mm/dd/yyyy

American College of Sports Medicine Fitness Pre-Participation Screening Questionnaire

HISTORY

Heart attack

Yes

Heart surgery

Yes

Cardiac catheterization

Yes

Coronary angioplasty (PTCA)

Yes

Pacemaker/implantable cardiac defibrillator/rhythm disturbance

Yes

Heart valve disease

Yes

Heart failure

Yes

Heart transplantation

Yes

Congenital heart disease

Yes

SYMPTOMS

Experience chest discomfort with exertion

Yes

Experience unreasonable breathlessness

Yes

Experience dizziness, fainting, blackouts

Yes

Take heart medications

Yes

OTHER HEALTH ISSUES

Experience musculoskeletal problems

Yes

Have concerns about the safety of exercise

Yes

Currently takes prescription medication(s)

Yes

Is currently pregnant

Yes

CARDIOVASCULAR RISK FACTORS

Male older than 45 years

Yes

Female older than 55 years or has had a hysterectomy or is post-menopausal

Yes

Smoke

Yes

Blood pressure is > 120/80

Yes

Blood pressure is not known

Yes

Takes blood pressure medication

Yes

Blood cholesterol level is > 240 mg/dl

Yes

Has a close blood relative who had a heart attack; before age 55 if father/brother or before age 65 if mother/sister

Yes

Physically inactive

Yes

> 20 pounds overweight

Yes

If you answered YES to two or more questions, please speak with your doctor and have them fill out a Medical Clearance form BEFORE you participate in a personal fitness training session.

INFORMED CONSENT AND RELEASE

I have been informed by the instructor of this City of Boulder class or activity that in addition to the risk(s) normally inherent to exercise, my written responses on the PAR-Q indicate that I may be subject to an additional or elevated risk(s) from exercise. I have reviewed my completed PAR-Q with the instructor of this class or activity, who on this basis recommended strongly that I obtain medical clearance from my doctor before participating in this class or activity.

I nonetheless elect voluntarily to participate in this class or activity prior to, or in lieu of, obtaining medical clearance from my doctor. I acknowledge that I have been informed fully of the potential additional risk(s) of my participation in this class or activity. I understand and accept voluntarily these additional risk(s).

I release all claims which may arise against, and agree not to sue, the City of Boulder and its officers, agents, employees and authorized volunteers, on my behalf as a result of participating in this class or activity.

I further agree to indemnify, hold harmless and defend the City of Boulder and its officers, agents, employees, and authorized volunteers from any and all claims by other parties resulting from injuries, damages, and losses caused by me arising out of, connected with, or in any way associated with this class or activity.

I read, understand, and agree with the Informed Consent and Release.

Name of Class or Activity:

Signature of Participant:

Parent/Guardian Signature (if under the age of 16):

Date

mm/dd/yyyy

Send me a copy of my responses

Report Abuse