PERSONAL TRAINING

Registration Form

For your ease of use, please complete this registration form on a computer.
Service Option: Jump Start = $35/$45 Training Package=$125/$150
Personal Information: Please type or print neatly, so we meet your needs accurately.
Name
Date of Birth
PID Number
Phone Number
Email Address
University Status 1st YR SO JR SR GRAD FAC/STAFF
Gender Male Female
Personal Trainer Gender Male Female No Preference
How did you hear about this Email Online SRC/RHRC Word of Mouth
service? DTH Special Event Other

Fitness Goals: Please indicate your priorities by ranking these six goals.

Revised 08.14.2008
 Most Least
Important Important
1 2 3 4 5 6
Click
-I
want
to
impro
ve my
cardio
vascu
lar
fitnes
s
Click
-I
want
to
reduc
e my
body-
fat

Click
-I
want
to
resha
pe or
tone
my
body
Click
-I
want
to
impro
ve my
athleti
c
ability

Click
-I
want
to
increa
se my
streng
th
Click
-I
want
to
impro
Revised 08.14.2008
ve my
flexibil
ity
Specifically, what do you hope to accomplish through your work with a Personal Trainer?

Availability: Please check times that you are available for Personal Training Sessions.
Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6am–11am
11am-3pm
3pm-7pm
7pm-12am
Specific
(optional)

Personal Trainer’s Use Only: Patron’s Specific Goals

1A. 1B. 1C.

2A. 2B. 2C.

3A. 3B. 3C.

Physical Activity Readiness Questionnaire [PAR-Q]

Please answer the following questions as honestly as possible.
Has your doctor ever said that you have a heart condition and recommended only
Yes No
medically supervised physical activity?
Do you feel pain in your chest as a result of 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 a bone or joint problem that could be made worse by a change in your
Yes No
physical activity?
Is your doctor currently prescribing drugs for your blood pressure or heart conditions? Yes No
Do you have any conditions or limitations that would hinder your ability to participate in
Yes No
physical activity? If yes, please explain:
Are you a female ≥ 55 years old or a male ≥ 45 years old? Yes No

Exercise History Questionnaire

Please answer the following questions as honestly as possible.
Were you a high school and/or college athlete? If yes, which sport(s): Yes No
Do you have any negative feelings toward, or have you had any bad experience with,
Yes No
fitness testing and evaluation?

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Do you start exercise programs and find yourself unable to adhere to them? Yes No
Do you currently exercise?
Yes No
If yes, please indicate major activities:
How long have you exercised on a consistent basis? months/ years
Rate your perceived exertion during your current exercise program (check the corresponding box):
Light Fairly Light Somewhat Hard Hard
Rate your exercise level on a scale of 1 to 5 (5 indicating very strenuous) for each age range through
your present age: 15-20 21-30 31-40 41-50+

Describe your ideal exercise plan: minutes/day days/week

Indicate the type(s) of equipment you enjoy using (check the corresponding box):
Exercise Bike Elliptical Rower Treadmill
Stair Climber / Stepmill Cybex / Life Fitness Machines (variable resistance)
Hammer Strength (plate loaded equipment) Free Weights

Please complete this registration form on a computer.

Please deliver the completed registration form and payment to 101 Student Recreation Center.
Jump Start (Fitness Check-up & 1 Session)
Student Fee: $35.00
Non-Student Fee: $45.00
Personal Training Package (Fitness Check-up & 5 Sessions)
Student Fee: $125.00
Non-Student Fee: $150.00
Campus Recreation accepts payment in the form of cash or ONE Card.

Email questions to: albertso@email.unc.edu

Revised 08.14.2008
 University of North Carolina at Chapel Hill – Department of Exercise and Sport Science

AGREEMENT AND RELEASE OF LIABILITY

In consideration of being allowed to participate in the activities and programs of the University
of North Carolina at Chapel Hill Department of Exercise and Sport Science and in consideration of the
voluntary nature of such participation and use, I hereby release, hold harmless, and forever discharge
The University of North Carolina at Chapel Hill, its employees and agents, from any and all liability,
claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss,
property damage, or personal injury, including death, that may be sustained by me or to any property
belonging to me, while participating in such activity.

I, the undersigned, hereby give permission for the staff of the University to seek emergency
medical attention to be given for me to receive medical attention in the event of accident, injury or
illness. I will be responsible for any and all costs of such medical attention and treatment.

I understand and am aware that strength, flexibility and aerobic exercise, including the use of
equipment, are potentially hazardous activities. I also understand that fitness and recreational activities
involve a risk of injury and even death, and that I am voluntarily participating in these activities and
using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly
assume and accept any and all risks of injury or death.

I do hereby further declare myself to be physically sound and suffering from no condition,
impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment
or machinery except as hereinafter stated. I acknowledge that I have either had a physical examination
and been given my physician’s permission to participate, or that I have decided to participate in activity
and use of equipment and machinery without the approval of my physician and do hereby assume all
responsibility for my participation and activities, and utilization of equipment and machinery in my
activities.

I am fully aware of the risks and hazards associated with participation in physical activity. I
hereby elect voluntarily to participate in said activity and fully acknowledge that the activity may be
hazardous to me and my property. I agree to comply fully with the rules/regulations and directions
provided by the staff at any of the EXSS/Campus Recreation facilities. Further, I understand that I will
be disqualified from the activity in the event that I fail to comply with said rules.

This release and hold harmless agreement is binding on myself, my heirs, my assigns, and
personal representatives.

I, _______________________________, am 18 years of age or older.

[Print]

_____________________________________ _______________________________
Signature Date

Administrative Use Only:

Service Option:  Jump Start  Training Package
University Status:  Student  Non-Student
Payment Amount:  $35.00  $45.00  $125.00  $150.00
Method of Payment:  Cash  ONE Card
Receipt #: ____________________
 Information added to Participant Tracker
Receptionist Initials: ______________________
Revised 08.14.2008