Fillable Pt Packet2019 2020 (Towson University)

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Pt Packet2019 2020 (Towson University)

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Campus Recreation
Fitness
Personal Training Registration Packet
CLIENT INFORMATION AND REGISTRATION PACKET
Welcome to Campus Rec at Towson University!
Thank you for your interest in our Personal Training program. If you choose to
participate, you will be paired with one of our nationally certified personal trainers that
will help you reach your fitness and exercise goals.
All information submitted in this packet will be kept confidential. Appropriate Campus
Rec staff will only access client information, which includes your current personal trainer
and the Assistant Director of Fitness.
If you are ready to get started, please follow these steps:
1. Complete this Personal Training Registration Packet. If you are unsure about any
information, your trainer can assist you during your consultation.
2. Return completed packet to Eric Barron (Burdick 251H) or ebarron@towson.edu
3. A personal trainer will contact you to set up your consultation/fitness assessment.
4. Please come dressed to work out for your first session. Please no jeans or open toed
shoes.
If you have, any further questions please contact Eric Barron, Assistant Director-Fitness
at 410.704.5360 or ebarron@towson.edu
2 | P a g e
TU ID #: ___________
Alumni Faculty/Staff
Name: __________________________________________
Email: ______________________
Contact Number/Cell Phone: _____________________
Best hours to be reached:________ Age: _____
TU Affiliation: Undergrad Student Grad Student
Emergency Contact Name: _____________________
Phone: __________________ Relation to you: _______________________
FITNESS ASSESSMENT
1 session, $15
INDIVIDUAL TRAINING PACKAGE OPTIONS (select one)
Bronze: 3 sessions, $80 student/$100 non-student
Silver: 5 sessions, $110 student/$150 non-student
Gold: 10 sessions, $200 student/$260 non-student
Tiger: 15 sessions, $285 student/$360 non-student
GROUP TRAINING/TWO PERSON PACKAGE OPTIONS (select one)
Silver: 5 sessions: $190 ($95/person)
Tiger: 10 sessions: $330 ($165/person)
Bronze: 3 sessions: $120 ($60/person)
Gold: 8
sessions: $275
($137.50/person)
**All packages begin with a fitness assessment and consultation on the first session.
Packages are non-refundable and must be used within 190 days of purchase.**
CANCELATION POLICY
There is no penalty for training sessions cancelled before 2 hours of your scheduled
training time. Failure to show up to a scheduled training session or tardiness of more
than 10 minutes will result in the loss of your training session. Please contact your
trainer directly or, call our Main Office at (410) 704-2367. Thank you for your
cooperation.
Participant Signature: _________________________________________________
IDEAL TRAINING TIMES
(Write time under the days you would prefer to train)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
click to sign
signature
click to edit
Trainer Preference:
____________________________________________________________
Personal Fitness Evaluation
Please fill out this form thoroughly and completely. If you have any questions, feel free
to ask our staff for assistance. Please be as honest as possible in your responses.
1. Do you have any negative feelings toward or have you had any bad experiences with
physical activity programs?
2. Do you have any negative feelings toward or have you had any bad experiences
with fitness testing and evaluation?
3. Rate yourself on a scale of 1 to 5, with 1 indicating the lowest value and 5 the
highest. Circle the most applicable to you.
Characterize your present athletic ability:
1 2 3 4 5
Characterize your present cardiovascular capacity:
1 2 3 4 5
Characterize your present muscular capacity:
1 2 3 4 5
Characterize your present level of flexibility:
1 2 3 4 5
4. Are you currently involved in regular exercise?
_____Yes _____No If yes, what type of
exercise:______________________
5. What types of activities interest you?
6. Do you enjoy participating in activities alone or in a group?
7. What barriers do you think have prevented you in the past from beginning or
adhering to an exercise program?
4 | P a g e
Rank your goals in undertaking exercise from 1 to 10, with 1 being the most important
to you.
_____Improve cardiovascular fitness _____Gain Weight
_____Reduce body fat level _____Exercise Ideas/Refresher
_____Reshape or tone my body _____Increase strength
_____Improve flexibility _____Increase energy level
_____Lose weight _____Other (please explain)
6 | P a g e
TOWSON UNIVERSITY CAMPUS RECREATION
FITNESS PROGRAM—PERSONAL TRAINING
AGREEMENT, WAIVER, HOLD HARMLESS AND COVENANT NOT TO SUE
Name (printed or typed):__________________________________________________
In consideration of my participation in Personal Training from July 1, 2019 to June
30, 2020, inclusive, I hereby freely agree to make the following contractual
representations and agreements:
I fully realize the dangers of participating in an event of this type and voluntarily
assume all the risks associated with such participation. I understand the risks include,
by way of example, and not limitation, the following: Accidents may happen while
traveling in vehicles to event locations including provided transportation, car pools,
bicycles, and walking. Injuries could result in concussion, broken bones, contusions,
torn muscles or tendons, strains, sprains, cuts, pinched fingers, neck and spinal injuries,
psychological trauma, hospitalization, and or death. I recognize that exercise is not
without some risk to the musculoskeletal system (e.g. sprain, strain, tear, break) and
cardio respiratory system (e.g. dizziness, fainting, abnormal heartbeat, discomfort
breathing, abnormal blood pressure response, and in rare instances, heart attack, or
stroke). I understand that it is my responsibility to report immediately to any Towson
University Personal Trainer if there are any signs or symptoms of discomfort and/or
distress during or following exercise.
I agree that it is my sole responsibility to be familiar with the physical and/or mental
demands associated with the above named events. With these demands in mind, I
have no physical or mental condition, which to my knowledge, would endanger myself
or others if I participate in this event, or would interfere with my ability to participate in
the event. I also agree to abide by any established rules or regulations while engaged
in this activity, and with the directions and precautions given by leaders and/or
instructors.
I understand that Towson University has no duty to provide any extraordinary duties or
safety measures in relation to this activity and that I must use reason and judgment in
my undertakings hereunder. I consent to Towson University providing emergency
health assistance if it is determined necessary in its discretion, and consent to Towson
University contacting my emergency contact for notification.
I understand and expressly assume all the risks and dangers of the activities
contemplated by this Agreement, and I hereby release, waive, discharge, and covenant
not to sue Towson University, the University System of Maryland, the State of Maryland,
and their officers, agents, servants, and employees (collectively, the “Releases”) from
all liability, claims, demands, actions, or causes of action whatsoever arising out of any
damages, loss, or injury to me or to my property while participating in any of the
activities contemplated by this agreement, whether such damage, loss, or injury results
from the negligence of the Releases or for any other cause. I also hereby release,
waive, discharge and covenant not to sue the Releases from any claims whatsoever on
account of any first aid, treatment, or service rendered to me during my participation in
the above activity. I hereby agree to indemnify and hold harmless the Releases from
any loss, liability, damage, or costs, including court costs and attorneys’ fees, that they
may incur due to my participation in said activities, whether caused by the negligence
of Releases or otherwise.
I agree, for myself and my successors, that the above representations and agreements
are contractually binding, and are not mere recitals. I agree that my failure or refusal
to sign such agreements or releases shall in no way affect the validity of this
Agreement, nor revoke or cancel any of the terms of this Agreement. I or any of my
successors shall be liable for the expenses (including legal fees) incurred by the party or
parties in defending against such claim or suit. This Agreement shall not be modified
orally.
I hereby certify that I have Health Insurance. My insurance company is:
_____________________________________________
I have carefully read this form and fully understand its contents. All information I have
provided is true. I am aware that this is a release of liability, a waiver of claims, an
agreement not to sue, an indemnity, and a contract between myself and Towson
University and for the benefit of others described herein, I sign it of my own free will.
_____________________________________________________________________
Participant’s Signature Printed Name Date
_____________________________________________________________________
Witness’s Signature Printed Name Date
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8 | P a g e
Fitness Assessment Preparation Guidelines
In order to assure that the results of your fitness assessment are as accurate as
possible, please review the following guidelines. Your assessment will be given on the
assumption that you have followed the recommendations.
1. Wear loose fitting clothes (jogging attire, shorts, training shoes, etc).
2. Avoid eating or drinking for 3 hours before your assessment.
3. Avoid alcohol, tobacco, and coffee for at least 3 hours before your assessment.
4. Avoid exercising on the same day as your assessment. Exercise will elevate your
blood pressure and resting heart rate – invalidating these measures.
Your fitness assessment will consist of measurements of one or more aspects of your
health and fitness. It may include your weight, cardiovascular condition (resting and
exercise heart rate and performance), body composition, musculoskeletal condition,
blood pressure, and body size (circumferences). The objective of your first assessment
is to give you a baseline from which to measure your performance. Subsequent
assessments will provide milestones help you evaluate your progress.
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Completed 18 July 2020

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