Personal Training Fitness Assessment (Page 5 of 5) in pdf

PERSONAL TRAINING REGISTRAION & WAIVER

2010 – 2011 ACADEMIC YEAR

(SEPTEMBER 5, 2010 – SEPTEMBER 3, 2011)

Today’s Date_______/________/________

(Month)

(Day)

(Year)

Personal Training Package: (all packages include intro session/fit assessment and body comp)

1 Session ($25 student, $40 non-student)

3 Sessions ($65 student, $115 non-student)

6 Sessions ($120 student, $180 non-student)

10 Sessions ($180 student, $250 non-student)

Fitness Assessment ($15)

Body Composition ($10)

Fitness Goals:

Improve cardiovascular fitness

Tone/reshape my body

Decrease body fat

Improve athletic ability

Increase strength

Improve flexibility

Build lean muscle mass

Decrease stress levels

Improve mood

Trainer Request______________________________

Please Print Clearly

Name of Applicant_________________________________________________________________________________

(Last)

(First)

(MI)

Date of Birth_________________________ UCARD #_________________________

Male

Female

Email__________________________________________________________

Phone__________________________

Local Address__________________________________________________

Apt #___________________________

City_______________________________

State________________________

Zip__________________________

Emergency Contact Name______________________________________

Relation to You_____________________

Emergency Contact’s Phone (primary)_________________________ Secondary Phone____________________

PARTICIPATION IN ANY ACTIVITY WITHIN THE RECREATION CENTER OR ANY OTHER RECREATION FACILITY

IS AT THE SOLE DISCRETION AND JUDGEMENT OF THE MEMBER AND AT HIS OR HER OWN RISK.

I, the undersigned, assume full responsibility for death, injuries, catastrophic injuries or damages which may occur to me in, on, or

about the premises of the facility and do hereby fully and forever release and discharge THE UNIVERSITY OF MASSACHUSETTS, the

Board of Trustees, employees and representatives from any and all suits, claims, damages, costs and expenses of every kind in

conjunction with the use of the Campus Recreation facilities and thereof equipment associated.

I, the undersigned, further agree to use all equipment and activity areas properly and leave them in good condition. I assume total

liability and agree to reimburse THE UNIVERSITY OF MASSACHUSETTS for all damages incurred through the misuse of any facility

area and/or equipment thereof. I also understand that the Recreation staff is not responsible for any lost, stolen or damaged personal

belongings.

I, the undersigned, have received the Personal Training Registration packet, policies and conduct of training sessions and

understand there are limitations to my participation as outlined in the packet.

I, the undersigned, certify that the information I have given on this form is complete and accurate.

Applicant’s Signature________________________________________

Date____________________________

RECREATION STAFF USE ONLY

Membership Classification:

Faculty / Staff

Graduate Student

Continuing Ed

Retiree

Associate

Alumni

Summer Undergrad

Package Purchased:

1 Session

3 Sessions

6 Sessions

10 Sessions

Fitness Assessment

Body Composition

Fee Amount $__________________

Method of Payment

Cash

Check #__________

CSI Invoice #___________________

Date of Purchase______________________

Expiration Date of Package_________________________

Staff Name___________________________________________

(Please Print Clearly)

Personal Training Fitness Assessment Page 5

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