PERSONAL TRAINING PROGRAM
YOUTH/TEEN NEW CLIENT PACKET
The information in this packet is necessary for developing safe,
effective, and appropriate programs for our clients. All
information is treated in the strictest manner with regards to
confidentiality and availability. The only individuals who have
access to the information are the Personal Trainer serving that
client, and the Fitness coordinator in the event of administrative
requirements. The forms should be filled out completely and
turned into the Personal Trainer upon the first visit.
Enclosed:
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Exercise and Physical Activity
Readiness Assessment
Health Status Questionnaire
Medical Release Form
Liability Waiver
24 Hour Cancellation Agreement
Exercise and Physical Activity Readiness Assessment
Complete each question accurately. All information provided is confidential.
Name_________________________
Date_______________
Height ____________ Weight ____________ Birth date ______________
Name/Parents/Guardians________________________________________
Address_________________________ Home Phone _________________
Cell Phone _________________ Work Phone _______________________
Emergency Contact Name/Phone _________________________________
Dr Name/Phone____________________________
Do you have any of the following? Please circle all that apply.
Epilepsy
Asthma
Diabetes
Heart Problems
Joint Problems
(Osgood Schlatters)
Movement
Disabilities
Allergies
(Please specify)
ADHD
Please list any medical conditions not listed_________________________
Please list any medications being taken ____________________________
How many hours a day do you watch TV? ___ Play on the computer? ___
How do you spend your time after school? _________________________
Please list any sports you are involved in ___________________________
How many hours a week do you train for your sport?__________________
How do you feel about exercising? ________________________________
MEDICAL RELEASE FORM
(If applicable)
Date_____________________________________
Dear Doctor;
Your patient_________________________________________________wishes to start a
personalized Training program.
The activity could include the following:
Type, frequency, duration, and intensity of activities)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If your patient is taking medications that will affect his/her heart rate response to exercise,
please indicate the manner of the effect (raises, lowers, or has no effect on heart rate response).
Type of medication:
___________________________________________________________________
Effect______________________________________________________________________
Please identify any recommendations or restrictions that are appropriate for your patient in this
exercise program:
____________________________________________________________________________
____________________________________________________________________________
Thank you.
Sincerely,
Highlands Ranch Community Association, Inc. (HRCA)
Name of Patient_________________________________has my approval to begin an exercise
program with the recommendations or restrictions stated above.
Signed___________________________________Date_____________
Phone___________________
PERSONAL TRAINER PROGRAM
24 HOUR CANCELLATION POLICY
Please read and sign below
NOTICE By signing this form and participating in the Personal
Training Program provided by the Highlands Ranch Community
Association, Inc. (HRCA), you acknowledge and agree that the
Personal Trainer reserves the right to charge you for a training session
if you do not give at least a 24 hour cancellation notice. This session
will be classified as a NO SHOW SESSION and will be deducted
from your session balance.
If you become aware that you can’t make a scheduled
appointment, you must follow one of the options listed below at
least 24 hours prior to the scheduled appointment in order not to
be charged for you session:
 Contact Personal Trainer on phone number
determined by you and your trainer
Signature_________________________ Date______________
PERSONAL TRAINING/FITNESS PROGRAMS
LIABILITY WAIVER
Please read and sign below
NOTICE By enrolling or participating in any
program and recreational activity provided or
sponsored by the Highlands Ranch Community
Association, Inc. (HRCA), members and guests
acknowledge and agree that there are certain risks
inherent in the programs and activities conducted at
HRCA’s Recreational Facilities or off-site programs,
which the members and guests assume. By enrolling
or participating in any program and recreational
activity, members and guests agree to waive any
claim of liability against HRCA and its members,
directors, officers, agents, employees and
contractors, related entities and affiliates and their
agents and employees, arising out of any loss, injury,
or death attributed to such risks and the use of
HRCA’s Recreation Facilities or off-site programs.
Signature of Participant ____________________Date _____________________
Parent/Guardian Signature _________________ Date _____________________