Training Request Form

TRAINING REQUEST FORM &
WAIVER & RELEASE FORM

CLIENT INFORMATION

Client's Name *

First Name Last Name

Client's Cell # *

Area Code Phone Number

Client's E-mail

Address *

Street Address

Street Address Line 2

City State

Zip Code

Gender *

Birthdate *

Date

Age *

Emergency Contact or Guardian/Parent Name (If participant is under age 18) *

First Name Last Name

EMERGENCY CONTACT INFORMATION

Emergency Contact or Parent/Guardian Email *

Emergency Contact or Parent/Guardian Cell # *

Area Code Phone Number

TYPE OF TRAINING

Which type of training are you interested in?

Personal Training Private Aquatics Coaching

PERSONAL TRAINING GOALS:

General Health (check all that apply):

Weight management Lower cholesterol Improve body composition Reduce stress Reduce my risk of disease

Fitness (check all that apply):

Increase aerobic capacity Increase muscular strength Improve flexibility Sports Specific Training Reduce my risk of disease

If You Checked "Sports Specific Training," please list sport(s) here:

Functional (check all that apply):

Improve balance Improve posture Reduce back pain Strengthen core (abs.back)

List any additional goals here:

AQUATIC TRAINING GOALS:

Check all that apply:

Endurance Turn improvement Improve times Stroke Development

If you indicated "Stroke Development" above, please specify stroke(s) below. List any additional goals below as well.

ADDITIONAL INFORMATION:

1. Please list any restrictions, injuries, medical conditions or joint limitations your trainer should be aware of (if none, please type, "None." *

2. Do you currently exercise? *

Yes No

If you answered yes, how often do you exercise? *

3. Desired number of training sessions per week: *

1 2 3 4 5 Don't Know

4. Preferred training days: *

Mon Tue Wed Thu Fri Sat

5. Please check the time(s) you are available to train: *

Early Morning (5:30-8 AM) Mid-Morning (8-11 AM) Early Afternoon (11 AM-2 PM) Late Afternoon (2-5 PM) Evenings (5-8 PM)

6. Do you have a Falling Springs approved trainer whom you would prefer to work with? *

Yes No

If yes, who? *

Do you have his/her contact info? *

Yes No

6. If no, please indicate your preference? *

Female Trainer Male Trainer No Preference

What type of session are you interested in? *

Single Session ($35) 5 Session Package ($160) 10 Session Package ($295) Buddy Single Session ($50) Buddy Package - 5 Sessions ($225) Buddy Package - 10 Sessions ($425)

If you selected Buddy training, what is your training buddy's name?

THIS IS A RELEASE AND WAIVER OF LIABILITY,
ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

IN CONSIDERATION of being permitted to participate in any way in the ACTIVITY/ACTIVITIES, EACH OF THE UNDERSIGNED, for him/herself, his/her personal representatives, heirs, and next of kin:

1. HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the Versailles‐Woodford County Parks & Recreation Department, and all of their directors, officers, agents, volunteers and employees, (hereinafter referred to as “Releasees”) FROM ALL LIABILITY TO THE UNDERSIGNED, his/her personal representatives, assigns, heirs and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFORE ON ACCOUNT OF INJURY AND/OR EXPOSURE TO INFECTIOUS SYNDROMES OR DISEASES TO THE PERSON OR PROPERTY OR RESULTING IN ILLNESS AND/OR DEATH OF THE UNDERSIGNED ARISING OUT OF OR RELATED TO THE EVENT(S), WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. BY PARTICIPATING OR ATTENDING THIS EVENT YOU ASSUME ALL RISKS WHETHER KNOWN OR UNKNOWN.

2. HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them FROM ANY LOSS, LIABILITY, DAMAGE, OR COST they may incur arising out of or related to the EVENT(S) WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or otherwise.

3. HEREBY acknowledges that THE ACTIVITIES OF THE EVENT(S) MAY BE DANGEROUS and involve the risk of exposure to infectious syndromes and diseases, serious illness, injury and/or death and/or property damage and he/she ASSUMES FULL RESPONSIBILITY FOR ANY RISK WHATSOEVER, INCLUDING BUT NOT LIMITED TO BODILY INJURY, EXPOSURE, DEATH OR PROPERTY DAMAGE arising out of or related to the ACTIVITY/ACTIVITIES whether caused by the NEGLIGENCE OF RELEASEES or otherwise.

V. I understand that all fees must accompany this application in order for it to be processed. I understand that if I need to cancel a training session, it is my responsibility to contact my trainer directly a minimum of 2 hours before my scheduled session. I understand that if I fail to give a minimum of 2-hour notice to my trainer that my session will not be rescheduled and that a refund will not be issued for the session.

VI. I understand and give permission for the Parks and Recreation Department or local media to photograph or video tape my child or me during participation this activity and to use them in advertising and promotion, both in print and on the Department’s website and social media outlets.

VII. In the event of an emergency, I give my permission for a representative of the Recreation Department and/or ambulance service to provide treatment as is normal and prudent and to transport my child or myself to the nearest medical facility to render treatment.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF ALL RISK, AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

Is the person who will be receiving training under the age of 18? *

Yes No

PARENT OR LEGAL GUARDIAN ACKNOWLEDGEMENT
(IF PARTICIPANT IS UNDER AGE 18)

I represent and warrant that I am the parent or legal guardian of the individual who will be receving training and that I have received, read, and understood the foregoing Release and Waiver. I fully consent to and voluntarily execute said Release and Waiver on Minor’s behalf. I acknowledge and agree that all representations, consents, agreements, grants, waivers, authorizations, indemnifications, and releases herein shall be regarded as made by me on behalf of the Minor and shall be binding on me and the Minor.

Furthermore, in consideration of Releasees possibly including me and/or Minor in the Event, I hereby agree to be bound by and to perform all of the terms and conditions of the foregoing Release and Waiver (including, without limitation, the provisions regarding release of all claims), as such terms and conditions may relate to my participation and/or the participation of the Minor in the Event, if any.

I have read, understood, and voluntarily accepted the conditions of the Waiver of Liability/Release and the Photo Release printed above. *

Yes No

Signature *

Clear

By signing above and typing my name below, I acknowledge that I have read and agree to the Waiver of Liability/Release and the Photo Release. I also understand and acknowledge that by typing my name below I am delivering an electronic signature that it will have the same effect as an original, handwritten signature and that the electronic signature will be equally as binding as a handwritten signature.

Type Name Here to Agree *

Date *

Month Day Year

HOW TO PURCHASE PRIVATE TRAINING SESSIONS

Below are details regarding purchasing your Personal Training Visits:

You may purchase your training visits now or after you've been contacted by a trainer.
When you purchase a training session or a block of training sessions, you will be issued a Personal Training Pass visit card loaded with the number of sessions you purchased
- If you already have a visit card of any kind to Falling Springs Center, then these training sessions will be added to your exisiting card.
- If you do not already have a visit card to Falling Springs, you will need to make arranments with the office regarding how you would like to receive your card (i.e, mail, pick-up in office, etc).
When you visit Falling Springs Center, you will scan your card at the check-in desk and tell the attendant that you would like to use a Personal Training visit and they will scan you in accordingly.

If you would like to purchase your training sessions today, please vist our online registration portal, WebTrac at https://webtrac.vwcparksrec.com, log in with your username & password (see below for details on how to log-in to WebTrac) and you add visits to an existing pass through the Memberships link.

If you would like to pay in person or with a credit card over the phone, please call or come by the Parks & Recreation offices M-Th from 9 AM to 6 PM or Fridays from 9 AM to 5 PM.

If you have any questions regarding this form or purchasing visit, please contact the main office at 859.873.5948 or email rjohns@vwcparksrec.com.

WEBTRAC INSTRUCTIONS FOR FIRST-TIME LOG IN:

1. Click Log‐in and enter your log‐in credentials. If you have had any transactions with Parks & Recreation in the past 7 years, you should already have an account in our system. If this is the case AND it is your first‐time logging into WebTracYour User Name & Password is your Household ID number for both fields.

a. You can find your Household ID on any receipt from a previous transaction with Parks & Recreation.

b. If you do not know your Household ID number or have an old receipt, please contact the office at 859.873.5948 and we can give you this information.

c. If you are new to Parks & Recreation or have not had any transactions within the past 7 years please click “If you’re a brand‐new patron with us, please click here to register for a new account,” and set up an account with your household information.

d. If you try to set up an account and you get a "Potential Duplicate Household," do not continue and call the Parks & Recreation Department at 859.873.5948.

2. Once you are logged in for the first time, please click on “MY ACCOUNT” and then click on “ACCOUNT SETTINGS” under the “UPDATE” column to update your username and password.

a. Enter your new username where it says “New Log‐in” and then re‐enter it on the line that reads “Re‐Type Login”

b. Please set your new Password where indicated.

c. If you would like to change your Primary email address, you can do so in the bottom section where it says, “Change your Email”.

d. Click submit to save changes.

3. Next, please click on My Account again and then click on Household & Member.

a. Please verify and make any changes to your address, phone numbers and other items as necessary and click save.

4. Click "HOME" on the navigation bar

5. Click "SEARCH" on the navigation bar and then click "MEMBERSHIP SELECTION."

6. Click the green plus sign next to the pass you want.

7. Click "Add to Card" in the bottom left hand corner.

8. Follow the prompts from there.