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Packet (Southeastern Louisiana University)

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U.S.A. forms for Southeastern Louisiana University

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Lighten Up Lions Sign-Up Form
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Name: ______________________________
W#: _________________________________
Age: ________________________________
SELU Email Address: __________________________________
Phone Number: ________________________________
Emergency Contact: ___________________________________
Relation: ___________________________
Phone Number: ___________________________
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Health & Medical History Questionnaire
Name: ___________________________ W#: ____________________________
Address: __________________________________________________________________
City State Zip
Birthdate (MM/DD/YYYY): __________________ Age: _________
Gender: __________________________ Ethnicity: _______________________
Occupation: _______________________
Physician’s Name: ________________________
Physician’s Phone #: ______________________
Date of last physical exam (MM/DD/YYYY): _________________
Height: ____________ Weight: _________________
Please describe any limitations/restrictions the Program Coordinator should be aware of:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Medications
(Include any over-the-counter medications, prescribed medications, and supplements)
NAME DOSAGE PURPOSE FOR HOW LONG?
Please list any special accommodations or needs:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any current fitness or sports activities (within the last 3 months):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Which of the following activity levels would you consider yourself as? (Check one)
_____ Sedentary/Inactive- do not participate in formal exercise & not physically active
during the day
_____ Light Physical Activity- activities that you do regularly as part of your day (ex:
walk to and from work for 15 minutes each way, raking leaves for 30 minutes, or playing an easy
game of ping pong for 20 minutes)
_____ Moderate Physical Activity- participating in cardiorespiratory endurance exercise
for 20-60 minutes, for 3-5 days a week (ex: jogging for 30 minutes, 3 days a week, or walking
briskly for 30 minutes, 5 days a week, or weight training, one set of 8 exercises, 2 days a week)
_____ Vigorous Physical Activity- exercising for 20-60 minutes on most days out of the
week, including aerobic exercise, interval training, strength training, and stretching exercises (ex:
running for 45 minutes, 3 days a week, or doing intervals, 2 days a week, or weight training, 3
days per week)
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!"#$%&'&(")*+#)*",&
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Name:!____________________________________! ! ! Date:!________________!
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Check!and!complete!at!least!3!goals!that!you!want!to!accomplish!by!the!end!of!this!fitness!program!(6!
weeks):!
____!Lose!!______!lbs!(1 lbs!to !2lbs !per!w e ek!o n!av era ge!is!rea so na ble !goa l) !
____!Lose!________!inch es!overall!
____!Decrease!BMI!by_________!% !
____!Increase!yo ur!overall!strength!and!core!strength!(as!measured !by!Microfit)!
____!Change!your!old!eating!habits!to!healthy!eating!habits!
____!Eat!_______!servings!_______!daily/weekly!(ex:!eat!2!servings!of!fruits!daily)!
____!Stop!or!decrease!the!amount!of!eating/drinking!___________!(ex:!sugar,!candy,!chips,!fast!food,!
etc.)!
____!Drink!6!to !8!cups!of!water!a!day!
____!Eat!a!healthy!breakfast!most!days!
____!Gain!confidence!in!yourself!!
!
Have!you!tried!to!start!a!healthy!behavior!in!the!past?!What!worked!and!what!did!not!work? !
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________!
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How!would!you!rank!your!stress!levels?!
1! 2! 3! 4! 5! 6! 7! 8! 9! 10!
(Least!amo un t)! ! ! ! ! ! ! ! ! (Highest!am o un t)!
! !
What!stresses!you!out?!
___________________________________________________________________________________!
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How!motivated!are!you!to!change?!
1! 2! 3! 4! 5! 6! 7! 8! 9! 10!
(Not!motiva ted )!! ! ! ! ! ! ! ! (Very!motiva ted )!
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Why!did!you!circle!that!number?!!
_____________________________________________________________________________________!
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Who!is!your!support!system?!Why?!
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________!
What!is!your!previous!workout!experience?!
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________!
What!are!your!workout!interests?!
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________!
What!workout(s)!are!you!not!interested!in?!
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________!
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Describe!your!current!exercise!routine.!!
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Tuesday!
Thursday!
Saturday!
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Record!what!you!ate!and!drank!within!the!past!24!hours.!!
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Breakfast!
Lunch!
Dinner!
Snacks!
Drinks!
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Questionnaire
Name: __________________________________ Date: ______________
W Number: ______________________________
Classification: ____________________________
How many hours are you taking this semester? ________
Are you a commuter or do you live on campus? ______________________
If you are a commuter, how far away do you live? ______________
For commuters, how willing are you to stay on campus to participate in L.U.L?
1 2 3 4 5 6 7 8 9 10
Not motivated at all Very motivated
Do you work? _____________ On campus or off campus? ___________
How many hours a week do you work? _________
Do you have a device that tracks your steps/physical activity (Apple Watch, FitBit, other)? _____
Please circle the following that apply to you.
Currently taking medications
Currently taking drugs that are not prescribed to you
Currently using tobacco products (vape, smokeless, etc.)
Consume caffeine
Have been diagnosed with a medical condition such as heart disease, diabetes, PCOS,
ets.
Have physical limitations
Other __________________________________________________________________
If you circled “currently taking medications,” please list the medications you are taking.
______________________________________________________________________________
If you circled “have been diagnosed with a medical condition,” please list the condition(s).
______________________________________________________________________________
If you checked “have physical limitations,” please list the physical limitation(s).
______________________________________________________________________________
Informed Consent
Program Objectives
I _______________________ understand that this physical fitness program is
individually tailored to meet the goals and objectives agreed upon by the Program Coordinator(s)
and myself. I understand, however, that the Program Coordinator(s) or physical fitness program
cannot guarantee that I will accomplish the established goals.
Description of Exercise Program
I ________________________ understand that the exercise program will involve
participation in a number of types of fitness activities. These activities will vary depending upon
the established objectives, but will probably include:
1) Aerobic activities including, but not limited to, the use of treadmills, stationary bicycles,
step machines, rowing machines, and running track;
2) Muscular endurance and strength building exercises including, but not limited to, the use
of free weights, weight machines, calisthenics, and other exercise apparatus; and
3) Selected physical fitness and body composition tests.
Description of Potential Risks
The Program Coordinator(s) explained that no exercise program is without inherent risks
and that, regardless of the care taken by the Program Coordinator(s) and/or fitness instructors, he
(or she) cannot guarantee my personal safety. For example, when one induces cardiovascular
stress through activity, injuries can range from minor injury (e.g., pulled muscles) to less
frequent serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) to the rare
catastrophic incident (e.g., death, paralysis).
I ________________________ realize that when participating in any exercises or
conditioning activity, there is always a possibility of minor injuries as well as a slight possibility
of major injuries or catastrophic injury/death.
Description of Potential Benefits
I _______________________ understand that a regular exercise program has been shown
to have definite benefits to general health and well-being. I know that some of the physiological
benefits of a regular exercise program can include loss of weight, reduction of body fat,
improvement of blood lipids, lowering of blood pressure, improvement in cardiovascular
function, reduction in risk of heart disease, improved strength and muscular endurance, improved
posture, and improved flexibility. I further understand that regular exercise can have
psychological benefits, often improving one’s outlook and feeling of well-being, as well as
relieving tension and stress.
Client Responsibilities
I _____________________ understand that it is the responsibility of client to:
1) Fully disclose any health issues or medications that are relevant to participation in a
strenuous exercise program;
2) Inform the trainer if there are activities with which I do not feel comfortable;
3) Cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea,
difficulty breathing); and
4) Clear my participation in an exercise program with a physician.
Client Acknowledgements
In agreeing to this exercise program, I ______________________:
• Acknowledge that my participation is completely voluntary.
• Understand that the potential physical risks involved in the exercise program and believe
that the potential benefits outweigh those risks.
• Give consent to certain physical contact that may be necessary to ensure proper technique
and body alignment.
• Understand that the achievement of health or fitness goals cannot be guaranteed.
• Have had a voice in planning and approving the activities selected for the exercise
program.
• Have been able to ask questions regarding any concerns and have had those questions
answered to my satisfaction.
• Acknowledge that I am in good physical condition, have no impairment which might
prevent participation in such activities, and have been advised to consult a physician prior
to beginning this program.
• Have been advised to cease exercise immediately if I experience unusual discomfort and
feel the need to stop.
Privacy
I ___________________ understand that my personal information, or any information
disclosed in this registration packet will be kept confidential, and will only be shared with
essential personnel as a need to know basis.
I ___________________ have read and understand that above agreement. I have been
made fully aware of and understand the potential risks involved in this physical fitness program.
I hereby consent to those risks and assert that I am freely and voluntarily participating in this
program.
Finally, I am freely signing this agreement.
____________________ ________ _____________________ ________
Signature of Client Date Signature of Trainer Date
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Liability Waiver
I expressly understand and agree to indemnify and save Southeastern Louisiana University, the
University Health Center, the Pennington Student Activity Center and the state of Louisiana
harmless from and against any and all claims, liabilities, costs, expenses, fires, injuries and/or
deaths, which arise from or are caused by, in whole or in part, directly or indirectly, the use of
College facilities or the activity hereby applied for the applicant, its employees, servants, agents,
invitees, or independent contractees. I further understand that use of College facilities, as a
voluntary request, is made at the sole risk of the applicant, and that neither the University Health
Center, the Department of Recreational Sports & Wellness, the Pennington Student Activity
Center, Southeastern Louisiana University nor the state of Louisiana make any representation,
expressed or implied, as to the suitability or fitness of such facilities.
I acknowledge that I am in good physical condition and that I will not engage in any activities
that may aggravate any present or future physical impairment that I have. I further agree to
follow all policies set forth in this document. The University Health Center and the Department
of Recreational Sports and Wellness strongly recommends that participants take a physical
examination before signing.
**If you have any physical restrictions, your physician MUST approve your activity. This form
must be accompanied by a letter from your physician approving your activity to include his/her
name, address and signature.
________________________________ ______________________________
Signature of Applicant Street Address
________________________________ ______________________________
Date City, State, and Zip Code
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Packet (Southeastern Louisiana University)

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Completed 20 July 2020

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