Personal Training Agreement
LA CROSSE AREA FAMILY YMCA
Personal Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact Information
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of trainer you will be working with (if applicable)
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Please review the information below so that you're familiar with the Y's personal training policies and procedures.
Refund Policy
Personal training sessions are non-refundable and non-transferrable.
Cancellation/Late Policy
All clients are required to give a 24-hour notice if they cannot make it to a training appointment. If the notice is less than 24 hours, it will be considered a training appointment and the client will be charged for that time. Clients who arrive late to their training session will not receive additional time beyond their scheduled hour. If you arrive more than 15 minutes late, your session may be canceled and you will still be charged. All personal trainers may give their clients their personal phone number at their own discretion. A client is to contact the personal trainer directly.
*
I have read the policies above. I understand and agree to the terms of the cancellation policy.
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Personal Training Release of Liability
1. I understand that participation in personal training and related physical activity involves inherent and unavoidable risks, including but not limited to strains, sprains, falls, equipment-related injuries, aggravation of pre-existing conditions, dizziness, fainting, shortness of breath, abnormal blood pressure, heart attack, stroke, other medical incidents, permanent disability, and death. I understand that my body’s response to exercise cannot be predicted with complete accuracy.
2. I understand that the YMCA and its personnel do not provide medical advice, diagnosis, treatment, or medical clearance. I am solely responsible for consulting with a qualified medical provider to determine whether I am physically and medically able to participate in personal training. I also understand that Inherent Risks remain despite any rules, supervision, instruction, equipment, facilities, or safety measures that may be provided by my medical provider.
3. If I become ill or injured while participating in YMCA activities, I authorize the YMCA to seek emergency medical assistance for me if YMCA personnel determine such assistance may be appropriate. I understand that the YMCA is not required to provide medical care and that I am responsible for all costs associated with medical treatment, transportation, emergency response, or related services.
4. I agree to comply with all YMCA personal training policies and program requirements. I understand that the YMCA may modify personal training fees as necessary by providing at least thirty (30) days’ advance written notice, which will apply after completion of any sessions already paid for.
5. I understand that the YMCA may make a self-administered Physical Activity Readiness Questionnaire (PAR-Q) available as an optional tool for my convenience. The PAR-Q is intended only to help me consider whether I may wish to consult with a qualified health care provider before participating in YMCA Activities. I understand that use of the PAR-Q is not required by the YMCA, is not medical advice, diagnosis, treatment, or medical clearance, and may be taken to my medical provider if I choose.
6. I hereby release, waive, discharge, and covenant not to sue the La Crosse Area Family YMCA, together with its officers, directors, employees, personal trainers, volunteers, agents, representatives, sponsors, affiliates, and insurers, from any and all claims, demands, causes of action, damages, losses, liabilities, costs, and expenses, including attorney fees, arising out of or related to my participation in YMCA Activities, their Inherent Risks, as well as ay claims arising from the ordinary negligence of any released party.
7. I agree to indemnify, defend, and hold harmless the released parties identified above from and against any and all claims, demands, causes of action, damages, losses, liabilities, costs, and expenses, including attorney fees, arising out of or related to: (a) my participation in YMCA Activities; (b) my acts or omissions; (c) my failure to follow YMCA rules, policies, instructions, or directions; (d) my failure to disclose relevant medical information; or (e) any claim brought by or on behalf of me, my heirs, personal representatives, family members, dependents, or assigns, except to the extent such claim cannot legally be indemnified under applicable law.
I have read this Agreement, understand that I am giving up substantial legal rights, including the right to sue for claims arising from ordinary negligence, and sign it freely and voluntarily. This Agreement is binding on me and my heirs, personal representatives, family members, dependents, successors, and assigns.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Parent/Guardian Agreement for Participant Under Age 18
I certify that I am the parent/legal guardian of the minor participant, have authority to sign this Agreement, consent to the minor’s participation in YMCA Activities, acknowledge the inherent risks, including serious injury, permanent disability, and death, and, to the fullest extent permitted by law, agree on behalf of myself and the minor participant to this Agreement’s assumption of risk, release, waiver, and indemnification provisions. I further agree to indemnify, defend, and hold harmless the released parties from claims, damages, losses, liabilities, costs, and expenses, including attorney fees, brought by or on behalf of the minor participant or arising from the minor’s participation in YMCA Activities, except to the extent such claim cannot legally be released or indemnified.
Guardian Signature
Date
-
Month
-
Day
Year
Date
Name/Relationship
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Physical Activity Readiness Questionnaire (PAR-Q)
PAR-Q (Physical Activity Readiness Questionnaire) helps determine if it's safe for you to begin or increase your physical activity.For most people, exercise is safe and beneficial. This questionnaire identifies anyone who may need to talk with a healthcare provider before participating.
Please read each question carefully and check Yes or No.
*
Rows
Yes
No
Has your doctor ever said you have heart trouble?
Do you frequently have pains in your and chest?
Do you often feel faint or have spells of severe dizziness?
Has a doctor ever said your blood pressure was too high?
Has your doctor ever told you that you have a bone or join problem(s) such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to?
Are you over the age of 60 and not accustomed to vigorous exercise?
Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness?
Are you currently taking any medications? If yes, please specify below.
Do you currently have a disability or a communicable disease? If yes, please specify below.
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Health History
Asses your health needs by marking all true statements.
History/You have had:
*
A Heart Attack
Heart Surgery
Cardiac Catheterization
Coronary Angioplasty (PTCA)
Pacemaker/Implantable Cardiac
Defibrillator/Rhythm Disturbance
Heart Valve Disease
Heart Failure
Heart Transplantation
Congenital Heart Disease
None of the above
If you marked any of the statements in this section, consult your physician or other appropriate health care provider before engaging in exercise.
Symptoms:
*
You experience ankle swelling
You experience unreasonable breathlessness
You experience chest discomfort with exertion
You experience dizziness, fainting, or blackouts
You experience unpleasant awareness of a forceful or rapid heart rate
You take heart medications
None of the above
Cardiovascular Risk Factors:
*
You are a man older than 45 years
You are a woman older than 55 years
You smoke, or quit smoking within the previous 6 months
Your blood pressure is > 140/90 mm Hg
You do not know your blood pressure
You take blood pressure medication
Your blood cholesterol level is > 200 mg/dL
You do not know your cholesterol level
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister).
You are physically inactive (i.e., you get < 30 minutes of physical activity on at least 3 days per week).
You have a body mass index over 30 kg * m-
You have prediabetes
You do not know if you have prediabetes
None of the above is true/applies to me
Other Health Issues:
*
You have diabetes
You have asthma or other lung disease
You have a burning or cramping sensation in your lower legs when walking short distances
You have musculoskeletal problems that limit your physical activity
You have concerns about the safety of exercise
You take prescription medications(s)
You are pregnant
None of the above
If you marked two or more of the statements in the Other Health Issues section you should consult your physician or other appropriate health care provider before engaging in exercise.
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