Please fill out the following form to request a private session with a personal trainer, yoga instructor, or aqua theraputic exercise practitioner. A certified trainer will call or email you to set up an appointment within 3 business days (M-F) from the time of recieving the request. 

This form also includes medical history information. Certain health conditions may require your physician’s approval prior to your first session.

If you have specific questions about the form, please contact Suzi Shankweiler, Fitness Supervisor, by phone at 303-833-3660 x 114 or email at sshankweiler@cvprd.com. 

Name of Participant (required)

Date (required)

Age (required)

Gender (required)

Male

Female

E-mail Address (required)

Phone (required)

Emergency Contact Name (required)

Emergency Contact Phone (required)

Relationship to Participant (required)

Preferred Session Day(s) (required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Session Time(s) (required)

Please Choose Private Session Option (required)

Aqua Stretch Therapy

Personal Training

Private Yoga

Preferred Trainer (You will be contacted within 3 business days after receipt of request.) (required)

Anastasia DeJulio: Personal Training and Private Yoga (availability varies)

Katy Fox: Aqua Stretch Therapy (availability varies)

Tana Greene: Personal Training (evenings)

Sheri Palizzi: Personal Training (weekdays)

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Participant's Health History

Name of Physician (required)

Physician’s Phone (required)

Are you taking any medications or drugs? (required)

Yes

No

If yes, what are you taking? (required)

Does your Physician know you are taking part in this exercise program? (required)

Yes

No

Describe your current exercise program: (required)

What would you like your trainer to know about your health and fitness goals? (required)

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Do you now have, or have you had in the past? (Please explain “yes” answers in comments)

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*If an asterisk question is marked yes, a physician’s release form must be completed and signed before personal training sessions can begin. Please have your physician email the form to Suzi Shankweiler at sshankweiler@cvprd.com.

*History of heart problems, heart attack, chest pain or stroke? (required)

Yes

No

*Increased blood pressure? (required)

Yes

No

*Diabetes or a thyroid condition? (required)

Yes

No

*Any conditions your physician should be aware of prior to exercise? (required)

Yes

No

Any chronic illness or condition? (required)

Yes

No

Difficulty with exercise? (required)

Yes

No

Advice from physician not to exercise? (required)

Yes

No

Surgery within the last 12 months? (required)

Yes

No

Pregnancy? Now or within the last 3 months? (required)

Yes

No

History of breathing or lung problems? (required)

Yes

No

Muscle, joint, or back disorder, or any previous injury still affecting you? (required)

Yes

No

Cigarette smoking habit? (required)

Yes

No

Obesity? More than 20% over ideal body weight? (required)

Yes

No

Increased blood cholesterol? (required)

Yes

No

Hernia or any condition that may be aggravated by lifting weights? (required)

Yes

No

Have you had any pain or discomfort with exercising in the past? (required)

Yes

No

Comments

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CANCELLATION POLICY: Trainers need a minimum of 24 hours notice if you are unable to make your appointment. If you fail to do so, you will be charged the full amount for the session.

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Private Sessions expire after one year from date of purchase.

Please Note: Payment is due prior to training sessions and consultations are included in the first paid session.

I have read and understand the above cancellation policy. I have reviewed and understand the Trainer and Client Expectation document (see document below). I certify that to the best of my knowledge, the enclosed statements are true and I understand that I am exercising at my own risk. (required)

Agree

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date (required)

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