Get Fit with Purpose The hardest part about getting fit is knowing where to start. Personal Trainers are guides who can help you start and maintain your fitness goals! Select your preferred branch below to learn more. BUTLER YMCA SELECT BRANCH ROSE E. SCHNEIDER FAMILY YMCA Select Branch New Client Personal Training Form contactinfo Name Email Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Select YMCA branch - Select -Butler YMCARose E. Schneider Family YMCA Gender - Select -MaleFemale Weight Height Date of Birth Exercise History/Past & Present Occupation Physical Non-Physical Are you currently exercising? Yes No How long have you been exercising? Briefly describe your current exercise routine/program Briefly describe the goals you have set to attain from your exercise program: Please indicate the best days and time of the week for you to train (ex. Mon. between 12pm-4pm): Preferred Trainer - Select -No preferenceKathy HenslerKelly RiddleErin NicotraWade RywoltAmy GilbertMary Lee MajewskiMarianne BiaseJon MurchakJessica ChastainJixing JensenKristie VassaloNancy TriscutKelly Brack Rate yourself on a scale of 1 to 10 1 Indicating the lowest value and 10 the highest. Select the number that applies most closely. Rate yourself on a scale from 1 to 10 Questions 1 2 3 4 5 6 7 8 9 10 Daily Stress Level 1 2 3 4 5 6 7 8 9 10 Competitive personality (pertaining to physical activity): 1 2 3 4 5 6 7 8 9 10 Aerobic (endurance) fitness: 1 2 3 4 5 6 7 8 9 10 Muscular (strength) level: 1 2 3 4 5 6 7 8 9 10 Flexibility level: 1 2 3 4 5 6 7 8 9 10 Select which most closely describes your diet - Select -high fat / hight sodium / low carblow fat / low sodium / high carbmoderate fat / moderate sodium / moderate carbI don't know / other Please describe your diet Are you currently on a calorie restrictive diet? Yes No How much time can you comfortably allocate per workout session based on your lifestyle? - Select -45 minutes or less45-60 minutes60-90 minutes Informed Consent for Exercise Participants Please review the Informed Consent For Exercise Participation document.With your signature, you affirm that you have read the Informed Consent For Exercise Participation document in its entirety and understand thenature of the exercise program. You also affirm that your questions regarding the exercise program have been answered to your satisfaction.Typing your name will act as your electronic signature. Signature Sign above Name of Personal Physician Physician's Address Physician's Phone Limitations & Medications PAR-Q+ Form A PAR-Q+ (Physical Activity Readiness Questionnaire for Everyone) is required to be completed prior to your assessment. (A YMCA Medical Clearance Form will be required if you answer “yes” to any of the PAR-Q+ questions.) Option 1: Complete an electronic PAR-Q+ form. Print the completion page and bring it with you to your first appointment. Option 2: Print and complete our PAR-Q+ printable form and return it at your first appointment. Select PAR-Q+ form option - Select -I completed the online form and will bring the confirmation page.I will complete and bring the printable forms. Signature Sign above Cancellation Policy Out of respect to the YMCA’s personal trainers we ask that anyone wishing to cancel a scheduled personal training session do so 24 hours in advance. Cancellations should be made through and confirmed by your personal trainer. Individuals that do not cancel within a 24 hour notice will be responsible for the personal training fee. The fee will be drafted or posted to the members YMCA account. Typing your name below will act as your electronic signature, confirming that you have read and agreed to the personal training cancellation policy stated by the YMCA. Signature Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
New Client Personal Training Form contactinfo Name Email Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Select YMCA branch - Select -Butler YMCARose E. Schneider Family YMCA Gender - Select -MaleFemale Weight Height Date of Birth Exercise History/Past & Present Occupation Physical Non-Physical Are you currently exercising? Yes No How long have you been exercising? Briefly describe your current exercise routine/program Briefly describe the goals you have set to attain from your exercise program: Please indicate the best days and time of the week for you to train (ex. Mon. between 12pm-4pm): Preferred Trainer - Select -No preferenceKathy HenslerKelly RiddleErin NicotraWade RywoltAmy GilbertMary Lee MajewskiMarianne BiaseJon MurchakJessica ChastainJixing JensenKristie VassaloNancy TriscutKelly Brack Rate yourself on a scale of 1 to 10 1 Indicating the lowest value and 10 the highest. Select the number that applies most closely. Rate yourself on a scale from 1 to 10 Questions 1 2 3 4 5 6 7 8 9 10 Daily Stress Level 1 2 3 4 5 6 7 8 9 10 Competitive personality (pertaining to physical activity): 1 2 3 4 5 6 7 8 9 10 Aerobic (endurance) fitness: 1 2 3 4 5 6 7 8 9 10 Muscular (strength) level: 1 2 3 4 5 6 7 8 9 10 Flexibility level: 1 2 3 4 5 6 7 8 9 10 Select which most closely describes your diet - Select -high fat / hight sodium / low carblow fat / low sodium / high carbmoderate fat / moderate sodium / moderate carbI don't know / other Please describe your diet Are you currently on a calorie restrictive diet? Yes No How much time can you comfortably allocate per workout session based on your lifestyle? - Select -45 minutes or less45-60 minutes60-90 minutes Informed Consent for Exercise Participants Please review the Informed Consent For Exercise Participation document.With your signature, you affirm that you have read the Informed Consent For Exercise Participation document in its entirety and understand thenature of the exercise program. You also affirm that your questions regarding the exercise program have been answered to your satisfaction.Typing your name will act as your electronic signature. Signature Sign above Name of Personal Physician Physician's Address Physician's Phone Limitations & Medications PAR-Q+ Form A PAR-Q+ (Physical Activity Readiness Questionnaire for Everyone) is required to be completed prior to your assessment. (A YMCA Medical Clearance Form will be required if you answer “yes” to any of the PAR-Q+ questions.) Option 1: Complete an electronic PAR-Q+ form. Print the completion page and bring it with you to your first appointment. Option 2: Print and complete our PAR-Q+ printable form and return it at your first appointment. Select PAR-Q+ form option - Select -I completed the online form and will bring the confirmation page.I will complete and bring the printable forms. Signature Sign above Cancellation Policy Out of respect to the YMCA’s personal trainers we ask that anyone wishing to cancel a scheduled personal training session do so 24 hours in advance. Cancellations should be made through and confirmed by your personal trainer. Individuals that do not cancel within a 24 hour notice will be responsible for the personal training fee. The fee will be drafted or posted to the members YMCA account. Typing your name below will act as your electronic signature, confirming that you have read and agreed to the personal training cancellation policy stated by the YMCA. Signature Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
