Personal Training Request Please read our Personal Training Policies prior to requesting sessions. PFT Program Policies Personal Training Request Step 1 of 2 - General Information 50% Name* First Last Email* Phone*GenderMaleFemaleOtherDate of Birth Membership Type*StudentUREC MemberWould you like to work with a male or female trainer?MaleFemaleDoesn't matterWhat do you hope to achieve by participating in Personal Training?*How often would you like to work with a trainer?*1x per week2X per week3X per weekWhat is your availability to work with a trainer?*Please list day(s) and time(s).Please check the services you would like:*Personal Fitness Profile ONLY1 1-hour session5 1-hour sessions10 1-hour sessions5 30-minute sessions10 30-minute sessionsA Personal Fitness Profile is required for all new clients purchasing Personal Training Sessions. How did you hear about Personal Training?UREC WebsiteSocial Media PostPoster or FlyerFrom a Friend Exercise Pre-participation Health Screening QuestionnaireSTEP 1 - SYMPTOMS: Do you experience any of the following? Check all that apply:* chest discomfort with exertion unreasonable breathlessness dizziness, fainting, blackouts ankle swelling unpleasant awareness of a forceful, rapid or irregular heart rate burning or cramping sensations in your lower legs when walking short distance I do not experience any of the above symptoms. If you DID mark any of the symptoms above, STOP, you should seek medical clearance before engaging in or resuming exercise. If you DID NOT mark any symptoms above, continue to steps 2 and 3.STEP 2 - CURRENT ACTIVITY: Do you currently perform planned, structured physical activity at least 30 minutes at a moderate intensity on at least 3 days per week for at least the last 3 months?*YesNoSTEP 3 - MEDICAL CONDITIONS: Have you had or do you currently have any of the following? Check all that apply.* a heart attack heart surgery, cardiac catheterization, or coronary angioplasty pacemaker/implantable cardiac defibrillator/rhythm disturbance heart valve disease heart failure heart transplantation congenital heart disease diabetes renal disease I do not or have not had any of the above medical conditions. Evaluating Steps 2 and 3: • If you did not mark any of the statements in Step 3, medical clearance is not necessary. • If you marked Step 2 “yes” and marked any of the statements in Step 3, you may continue to exercise at light to moderate intensity without medical clearance. Medical clearance is recommended before engaging in vigorous exercise. • If you marked Step 2 “no” and marked any of the statements in Step 3, medical clearance is recommended. You may need to use a facility with a medically qualified staff.