PAR-Q Form

Your Name

FirstLast

Your Birthdate

Phone

Email

Your Address

Street AddressAddress Line 2City

StateZIP Code

Your Physician's Name

FirstLast

Your Physician's Phone

PHYSICAL READINESS QUESTIONNAIRE

Please check yes or no to each of the following questions.

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

Yes
No

Do you frequently have pains in your chest when you perform physical activity?

Yes
No

Have you had chest pain when you were not doing physical activity?

Yes
No

Do you lose your balance due to dizziness or do you ever lose consciousness?

Yes
No

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?

Yes
No

Are you pregnant now or have given birth within the last 6months?

Yes
No

Have you had a recent surgery?

Yes
No

If you have marked YES to any of the above, please elaborate below:

Do you take any medications, either prescription or non-prescription, on a regular basis?

Yes
No

What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

Terms, Conditions & Release

Please read, check the “I have read and understand this term” boxes and sign below:

If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. *

I have read and understand this term.

I certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform all employees of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.*

I have read and understand this term.

I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer, Group Fitness Instructor or alternate staff.*

I have read and understand this term.

I understand the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions. *

I have read and understand this term.

I understand that all Private Personal Training rates are based on 30 or 55 minute sessions and should I arrive late, there is no guarantee I will receive the full session with my trainer. In return, if my Personal Trainer is late for a session, I will still receive the full session time.

I have read and understand this term.

I understand that Angie Gooding, LLC bills its Personal Training clients on a pre-pay basis. Once my trainer and I have decided upon the type of training package and payment plan I will purchase, payment must be made before the sessions are conducted. Cash and checks made payable to Angie Gooding, LLC, and payments via PayPal are all accepted. I understand that all Personal Training sessions are non-transferable and non-refundable.

I have read and understand this term.

All appointments will be scheduled ahead at the time of purchase; I understand that if I must reschedule any session, I aknowledge that I must reschedule that session in the same week as it was originally scheduled. Any sessions that are not rescheduled to within 6 days of the end of the originally scheduled term shall be lost and will not be rescheduled.*

I have read and understand this term.

I understand that, for the benefit and consistency of my program, that I will need to schedule with Angie a minimum of 1 appointment per week. All unused sessions will expire at the end of the allotted time.

I have read and understand this term.

I understand that Angie Gooding, LLC operates on a scheduled appointment basis for all Private Training sessions and thus, requires that I provide 24 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given. Should I cancel a session with LESS than 24 hours prior notice, I will be charged in full for that session, unless the session is rescheduled within the same week. All cancellations must be made by phone (no text or email cancellations).

I have read and understand this term.

If, for an injury or another medical reason, I need to put my sessions on hold, I may do so for up to 30 days. I understand that it is my responsibility to reschedule and resume sessions with Angie. I also understand that if sessions go unused, they will expire after these 30 days and/or within the allotted term.

I have read and understand this term.

I understand that during a personal training or group training session, my trainer/instructor may have to use Touch Training to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch Training, I will immediately request that it be discontinued

I have read and understand this term.

I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by my Personal Trainer or any other staff member.

I have read and understand this term.

I understand that Angie Gooding, LLC photographs many of their client events/sessions and I give my approval for them to be used for promotional purposes.

I have read and understand this term.

Release of Responsibility

The undersigned, the client, knows that the client’s participation in the personal training program that is the subject of the foregoing Personal Training contract may place the client at risk of physical injury and other damage and loss, resulting from the acts, or failure to act, of the client, the trainers, training facilities, or third parties. Having such knowledge in mind, the client does hereby voluntarily accept the risk of such injury, damage, and loss, and in consideration of the benefits to client from the said personal training program, and other good and valuable consideration, receipt of which is hereby acknowledged, does hereby release and forever discharge Angie Gooding, LLC and Angela M. Gooding, (who is sometimes referred herein as trainer), fitness facilities, and their respective marital communities, successors, heirs, and assigns, of and from all manner of actions, causes of action, claims, suits, and demands whatsoever, which client has or may have by participation in the said personal training program, including without limitation, death, personal injury, bodily or mental injury, economic loss and damages of any of the trainers, the fitness facilities, their employees and agents.

Participant certifies that he/she has read, understood and agrees to the above terms and conditions.*

By checking this box, I pledge that I have read this Personal Readiness Questionnaire, Release and Terms of Agreement and I understand all of its terms. I agree to it voluntarily and with full knowledge of its significance.

Agreement Date