Clemson University Online Forms

Personal Training Registration Form

* Denotes a required field

Name *

First NameLast Name

Date of Birth *

/ / (mm/dd/yyyy)

Preferred Address *

Line 1
Line 2
, City, State, Zip

Phone Number *

-- Ext.

Email Address *

name@example.com

Gender *

Fike Recreation Center Membership Type *

CUID or Member ID Number *


Please select Personal Training Package:

Individual Personal Training Packages (1-hour Sessions):

Three - [Student $90, Member/Employee $150]
Five - [Student $140, Member/Employee $225]
Eight - [Student $210, Member/Employee $340]
Ten - [Student $240, Member/Employee $410]
Twelve - [Student $265, Member/Employee $470]
One - Fitness Assessment [Student $10, Member/Employee $15]

Group Personal Training Packages (*Please note: Only groups of 3-6 individuals qualify for these rates. Prices shown are PER PERSON)

Three - [Student $15, Member/Employee $20]
Five - [Student $25, Member/Employee $30]
Eight - [Student $35, Member/Employee $40]
Ten - [Student $45, Member/Employee $50]
Twelve - [Student $55, Member/Employee $60]

If you have selected Group Personal Training, please write the names of other members in your group.

Trainer Preference: *

Male
Female
No preference

Please list any fitness, health, or wellness goals you wish to achieve with a Personal Trainer. These goals will help us match you with the mot appropriate Trainer for your needs.

Describe your regular physical activity or exercise program:

Type:

Frequency: (days per week)

Duration: (minutes)

Intensity:

Availability Calendar: *

Monday AM
Tuesday AM
Wednesday AM
Thursday AM
Friday AM
Saturday AM
Sunday AM
Sunday PM
Monday 12PM - 4PM
Monday 4PM - Close
Tuesday 12PM - 4PM
Tuesday 4PM - Close
Wednesday 12PM - 4PM
Wednesday 4PM - Close
Thursday 12PM - 4PM
Thursday 4PM - Close
Friday 12PM - 4PM
Friday 4PM - Close

Other:


Eligibility and Payment Agreement

1. Clients must hold a current Fike Recreation Center membership via being a Clemson University student or member of the facility.

2. All personal training fees must be paid in full at the Welcome Center in Fike Recreation Center prior to starting any training sessions.

3. All paperwork must be completed prior to any Personal Training services.

4. The Department of Campus Recreation reserves the right to deny services to any participant who may not be able to exercise safely within the parameters of the Personal Training program.

5. Individual Personal Training packages may not be split with other clients in any way, regardless of their relationship to the client. Small Group Training sessions will be conducted with one Personal Trainer.

6. Personal Trainers will not accept any direct or additional payment for their services.

7. Personal Training sessions are non-transferable and non-refundable. Medical conditions which prevent the sessions from being redeemed within a 90-day expiration period may be refunded if a physician's note is provided.


Training Guidelines

1. All Personal Training sessions will be conducted in Fike Recreation Center or surrounding areas.

2. Clients must adhere to all Fike Recreation Center membership and facility policies and procedures found in the Campus Recreation Policy Handbook.

3. Clients must report to the lobby of Fike Recreation Center to meet their trainer before each session.

4. Training sessions must be completed within 90 days of the purchase date.

5. Cancellations must be made a minimum of 24 hours prior to any scheduled session. If a cancellation is not made a minimum of 24 hours prior to any scheduled session, the client will be charged for the full session. The same applies for a "no-show."

6. Only current Campus Recreation Personal Trainers will conduct training sessions.

7. Appropriate attire must be worn during all training sessions. Please refer to the Campus Recreation Policy Handbook for guidelines.

8. All training sessions begin at the time agreed upon by the Personal Trainer and client. If a client is late, time will be deducted from the session.

9. Prior to starting any sessions, Personal Trainers will conduct an initial consultation and fitness assessment. Baseline information will be collected, upon which the trainer can create an appropriate, individualized training regimen. Clients are recommended to follow the Fitness Assessment Guidelines.


Initial Here: *


Physical Activity Readiness Questionnaire - PAR-Q

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

Yes
No

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

Yes
No

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

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes
No

Do you have bone or joint problem (for example; back, knee, or hip) that could be made worse by a change in your physical activity? *

Yes
No

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

Yes
No

Do you know of any other reason why you should not do physical activity? *

Yes
No

Health/Medical History Form

Are you currently under medical supervision? *

Yes
No

Do you see a chiropractor? *

Yes
No

Do you have any allergies? *

Yes
No

Are you currently taking any medicine? *

Yes
No

Have you ever had a definite or suspected heart attack or stroke? *

Yes
No

Have you ever had coronary bypass surgery or any other type of surgery? *

Yes
No

Do you have any cardiovascular disease or pulmonary (lung), disease? *

Yes
No

Do you have asthma? *

Yes
No

Do you have a history of diabetes, thyroid, kidney, or liver disease? *

Yes
No

Do you currently have difficulty breathing at night except in upright position? *

Yes
No

Do you currently have shortness of breath? *

Yes
No

Do you currently have swelling of the ankles (recurrent and unrelated to injury)? *

Yes
No

Do you currently have heart palpitations (irregularity or racing of the heart on more than one occasion)? *

Yes
No

Do you have a known heart murmur?

Yes
No

Are you pregnant or is it likely that you could be pregnant at this time? *

Yes
No

Have you had surgery or been diagnosed with any disease in the past 3 months? *

Yes
No

Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids? *

Yes
No

Do you currently smoke cigarettes or have you quit within the past 6 months? *

Yes
No

Currently, do you have high blood pressure or within the past 12 months, have you taken any medication to control your blood pressure? *

Yes
No

Within the past 12 months, has a health professional told you that you have high blood pressure (systolic > 140 OR diastolic >90)? *

Yes
No

Do you have problems with bones, joints, or muscles that may be aggravated with exercise? *

Yes
No

Do you have any back/neck problems? *

Yes
No

Have you been told by a health professional that you should not exercise? *

Yes
No

Are you currently being treated for any other medical condition by a physician? *

Yes
No

Are there any other conditions (mitral valve, epilepsy, history of rheumatic fever, cancer, anemia, hepatitis, etc.) that may hinder your ability to exercise? *

Yes
No

Please explain any YES answers from above here: *

**Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional immediately. Ask whether you should change your physical activity plan.


I have read, understood and completed this PAR-Q and Health History Form accurately and completely. I understand that my medical history is a very important factor in the development of my fitness/wellness program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my trainer, may result in serious injury to me. If any of the above conditions change, I will immediately inform my trainer of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the above questionnaire. Any questions I had were answered to my full satisfaction.


*

First NameLast Name