Personal Training Request Form

PERSONAL TRAINING
REQUEST, WAIVER & RELEASE FORM

CLIENT INFO

Client's Name *

First Name Last Name

Client's E-mail

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Gender *

Birthdate *

Date

Age *

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

First Name Last Name

Emergency Contact or Parent/Guardian Email *

Emergency Contact or Parent/Guardian Cell # *

- Area Code Phone Number

HEALTH & FITNESS GOALS: (please check all that apply)

General Health:

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

Fitness:

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:

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

List any additional goals here:

Please list any restrictions, injuries, medical conditions or joint limitations your trainer should be aware of:

To help us pair you with the most appropriate personal trainer, please answer the questions below:

1. Do you currently exercise? *

If you answered yes, how often? *

2. Desired number or personal training sessions per week: *

3. Preferred training days: *

Mon Tue Wed Thu Fri Sat

4. 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)

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

If yes, who? *

Do you have this trainer's contact info? *

If no, please indicate your 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? *

AGREEMENT

WAIVER OF LIABILITY AND TERMS OF PARTICIPATION:

I. I recognize and acknowledge that there are certain risks of injury and I waive and relinquish all claims I or my children may have as a result of participation in this program against Woodford County, the City of Versailles, the Versailles-Woodford Co. Parks & Recreation Department and it’s officials (either elected or appointed), commissioners, officers, agents, employees and volunteers. I further agree to indemnify, hold harmless and defend Woodford County, the City of Versailles, Versailles-Woodford Co. Parks & Recreation and it’s officials (either elected or appointed), commissioners, officers, agents, employees and volunteers from and against any and all claims, suits or cause of actions, including reasonable attorney’s fees, sustained or caused by myself or my child arising out of, in connection with, or in any way associated with the activities of this program.

II. If the participant is under 18 years old, I hereby give my child/children permission to participate in this activity and on the child’s behalf as parent and/or legal guardian I hereby waive, release and forever discharge any and all claims against the County of Woodford, the City of Versailles, the Versailles-Woodford Co. Parks & Recreation Department and it’s officials (either elected or appointed), commissioners, officers, agents, employees and volunteers for damages and/or injuries which may arise from my child’s participation in this program.

III. I, the undersigned, understand and acknowledge that participation in a recreational or fitness activity can be hazardous and I realize that no one should enter into a recreation or fitness activity unless the participant is medically able. I/We assume all risk associated with this activity including, but not limited to falls, contact with other participants or equipment, effects of weather, equipment failure and condition of playing area. I fully understand that is my responsibility to ascertain if this specific activity contains other elements of risk that could prove to be harmful to a participant.

IV. Having read this waiver and in consideration of acceptance of entry into this program, I and anyone entitled to act on my behalf waive and release Woodford County, City of Versailles, Versailles-Woodford Co. Parks & Recreation, it’s co-sponsors, their representatives and successors from all and against any and all claims, suits, or cause of actions, including reasonable attorney’s fees, sustained or caused by myself or my child arising out of, in connection with, or in any way associated with the activities of this program.

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

Yes No

By 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 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

PURCHASE PERSONAL TRAINING SESSIONS

Below are details regarding purchasing your Personal Training Visits:

Y ou 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 complete the section below and make payment via PayPal. If you would like to pay in person, you should stop by the Parks & Recreation office to purchase your sessions. The office is open M-F from 9 AM to 6 PM or by appointment.

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.

Purchase Training Visits

Single Session $ 35.00

Quantity

5 Session Package $ 160.00

Quantity

10 Session Package $ 295.00

Quantity

Buddy Single Session $ 50.00

Quantity

Buddy Package - 5 Sessions $ 225.00

Quantity

Buddy Package - 10 Sessions $ 425.00

Quantity

Total $ 0.00