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Programs
Fitness Assessments
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Fitness Assessment Intake Form
Fitness Assessment Intake Form
Fitness Assessment
Step
1
of
4
25%
Date
MM slash DD slash YYYY
Name
*
First
Last
Email
*
Phone
*
Birthday
*
MM slash DD slash YYYY
Membership Status
*
Moraine Student
Moraine Faculty/Staff
FitRec Member
Non-Member
Availability
Select all that apply
Monday
Morning (before noon)
Afternoon (12-5 p.m.)
Evening (after 5 p.m.)
Tuesday
Morning (before noon)
Afternoon (12-5 p.m.)
Evening (after 5 p.m.)
Wednesday
Morning (before noon)
Afternoon (12-5 p.m.)
Evening (after 5 p.m.)
Thursday
Morning (before noon)
Afternoon (12-5 p.m.)
Evening (after 5 p.m.)
Friday
Morning (before noon)
Afternoon (12-5 p.m.)
Evening (after 5 p.m.)
Saturday
Morning (before noon)
Afternoon (12-5 p.m.)
Evening (after 5 p.m.)
Which Fitness Assessment Service did you choose?
*
Body Composition Full Assessment
Body Composition Single Assessment
Cardiorespiratory Single Assessment*
Muscular Strength Single Assessment*
Muscular Endurance Single Assessment*
Flexibility Single Assessment
Posture/Balance Single Assessment
Full Fitness Assessment (All of the above)*
Select the one that applies. *May be required to obtain physician clearance prior to assessment appointment. Participants who have heart, lung or diabetic conditions will need clearance.
I Understand...
• To begin this process, please purchase your Fitness Assessment sessions at Membership Services • Please give this Intake Form and the Questionnaire to the Membership Service staff member when completed. • A Professional Staff Member/ Personal Trainer will be assigned to you based on your intake form information and the availability of the trainer. You will be contacted within 2-3 days to establish your appointment and consultation. • Policies: Length of Sessions: In order to answer questions and complete fitness assessment, most appointments will take 15-30 minutes, with the exception of the Body Age Fitness Assessment which takes one hour to complete. Private Appointment Cancellation Policy: to cancel an appointment, contact the Personal Trainer directly, at least 4 hours in advance. Failure to do so will result in forfeiting the session. Late Policy: Personal Trainers will still honor the appointment in the event a client is late; however, sessions that begin late will end at the originally scheduled time. Expiration Policy: All personal training session expire one year from date of purchase. Refund Policy: All sessions are non-refundable. If dissatisfied with a trainer or trainer’s service, a client may request a replacement personal trainer through the Program Coordinator.
Authorization
*
I certify that by typing my name in this field that I have read the policies and applicable waiver pertaining to this program, and I agree to the conditions set forth herein.