Pre-Training Application — Stephen Cooper Training

Section 1: Basic Information

Email

How did you hear about me?

Which are you most interested in: personal training, boot camp, senior fitness, small group sessions, or just trying out a class? And when would you like to start?

Section 2: Medical & Safety Screening

Please answer honestly. These questions are based on the standard Physical Activity Readiness Questionnaire (PAR-Q).

Emergency Contact (Name & Phone)

Name and phone number.

Physician Name & Phone

Are you currently taking any medication for blood pressure, heart, or other conditions?

If so, list medications and doses.

Do you know of any other reasons you should not engage in physical activity? If so, please let me know.

List any medications and doses you are currently taking.

Do you have any allergies?

Do you have any physical limitations that would limit your ability to exercise? If so, what are they?

Please list dates, reasons, and outcomes of any surgeries, abnormal test results, and hospitalizations that you might believe would relate to exercise training.

Your digital signature and date.

Section 3: Goals & Lifestyle

What is your primary fitness goal?

Do you have a specific deadline for achieving it?

On a scale of 0–10, how important is this goal to you?

On a scale of 0–10, how confident are you that you can make this change?

What type of exercise or activity are you currently doing?

What do you like to do for fun?

What supplements (vitamins, protein, etc.) are you currently taking?

What are your biggest challenges or concerns about joining boot camp?

Is there anything else that you wish to share with me?

Section 4: Policies & Agreements

Informed Consent

The exercise sessions you will become involved with and undertake will consist of progressive exercise levels and be determined and regulated by your trainer. The exercise sessions will consist of aerobic and weight training as well as education and instruction. These exercises are designed to place a gradual increasing stress on the body and as such to improve the body’s function, although no guarantee can be made. I am aware that all activities are offered as recreational or self directed in nature and I have the right and choice to stop activity at any time. I also assume full responsibility during and after my participation for any risk, discomfort or fatigue that I may experience. I understand that exercise and cardiovascular activity and the response of my body to such activity cannot be predicted. I acknowledge my responsibility and obligation to inform the nearest supervising employee of any pain, discomfort, fatigue or any other symptoms that I may suffer and that it is my choice to participate in the training program. I also understand that my trainer or other staff may not be licensed, certified, or registered instructor and that skill levels may vary and that I accept assumption of all the risk that may imply as my own. The information made and obtained during the training sessions is treated as confidential. However it may be used for statistical purpose as long as my privacy is not compromised. I understand that I may ask any questions or request further information about any of the activities, programs, or services offered at any time before, during or after participation. I may take as long as I need to think the program over and can participate now or withdraw at any time. I have read the above and consent to participate in a fitness program.

Privacy Disclaimer

Your information will only be used for fitness screening and will not be shared without your consent. While this form is secure, please do not submit highly sensitive medical details (like full diagnoses) online. If needed, we will discuss these in person.