Seahawk Fitness
Personal Training
OFFICE
Student Recreation Center
601 S College Rd
Wilmington, NC 28403-5923
Welcome to Personal Training at Campus Recreation
PHONE
910-962-7443
FAX
910-962-3757
EMAIL
2bfit@uncw.edu
WEB
www.uncw.edu/campusrec
Thank you for choosing to participate in the personal training program at UNC Wilmington
Campus Recreation. Our trainers will use the information in this packet to formulate a program
that is effective and well suited to fit your needs. This packet contains the Personal Training
Registration, Exercise History, SMART Goal Setting, Health History, PAR-Q, and Assumption
of Risk Form. Please answer each question honestly and thoroughly. Once we have received your
completed payment and registration, you will be assigned a trainer based on your information and
preferences and be contacted by your trainer to schedule your first session within 48 business
hours.
Your first session will include an initial consultation and Level 3 Fitness Assessment.
Training Etiquette
In order to help make your personal training experience a positive one, we ask that you observe
the following training etiquette:
1. Payment must be received for training sessions before the initial consultation is given.
Trainers cannot accept payment; please pay for sessions at the Campus Recreation business
office (M-F 8:00 a.m.-5:00 p.m.) or via mail, show receipt of payment to your trainer. All
training sessions expire 90 days after purchase.
2. If you have any unexpected scheduling conflicts throughout your training experience, it
is your responsibility to notify your trainer directly at least 24 hours beforehand. Trainers are also
required to provide the same notification. If you are unable to reach your trainer, you can also
call the Department of Campus Recreation at 910.962.7443. Trainers will only wait 15 minutes
prior to forfeiting the session; sessions that begin late will still end at the regular scheduled time.
3. Be ready to work hard during each session; wear closed toe athletic shoes, athletic
clothing, and bring a water bottle.
Client Confidentiality & Trainer Evaluation
All information regarding your program and progress will be kept confidential and will remain in
our client files for 3 years following the cessation of your participation in the program. All
Personal Trainers have signed a statement of confidentiality at the beginning of employment.
Following the completion of your training package, you will be asked to evaluate your trainer as
well as the personal training program offered by Seahawk Fitness and Campus Recreation. At
this time you will also have the opportunity to complete a post fitness assessment that will
illustrate your progress through participation in the personal training program.
We hope you find that your sessions are well organized and informative. If you have any
questions or comments about the Seahawk Fitness Personal Training program, please contact
2bfit@uncw.edu.
Seahawk Fitness
Personal Training
Date Received:__________________
Registration Information
FULL NAME:
UNCW ID:
PHONE:
EMAIL:
GENDER: Male
Female
STATUS (circle one): Undergraduate Student
Graduate Student Faculty/Staff Other: _________
Date of Birth:
Major/Degree/Department: ___________________
Classification (undergrad):
Fr
So
J
r
Sr
Campus/Local Address:
Permanent (if different):
How did you hear about the program?
Trainer Preference:
Male
Female
Name:
Student Cost
Faculty/Staff Cost
Member Cost
Individual
Partner
Individual
Partner
Individual
Partner
4 Sessions
$60
$45 each
$80
$60 each
$100
$80 each
8 Sessions
$110
$80 each
$150
$110 each
$190
$150 each
10 Sessions
$130
$100 each
$170
$130 each
$210
$170 each
12 Sessions
$150
$115 each
$200
$150 each
$250
$200 each
$330
$260 each
$180
$135 each
$250
$195 each
16 Sessions
Please Circle a Personal Training Package:
Partner Name (If applicable): ____________________________________________
Partner Training is limited to 2 persons only. Both partners will need to complete a registration packet. Partner Training is subject to rejection if both persons do not
have similar exercise levels and goals. Each client must register/pay separately.
Training Availability:
Desired number of weekly sessions: __________
Please mark the days you are available. Specify times if possible. (i.e. M, W, F from 2:00 to 4:00 p.m.)
Monday _________
Friday _____________
Tuesday _________
Saturday _____________
Wednesday ___________
Sunday ____________
Thursday _____________
Special Considerations (i.e., do you have any medical or other conditions your trainer should know about, etc.)
Page 2 of 9
Campus Recreation Office Use Only:
Seahawk Fitness Use Only:
Payment Amount: __________Payment Type: ______
Date Received: __________Date Entered: ______
Date Processed: ___________ Receipt No. ________
Trainer Assigned: ___________ Renewal: Y N
Processed by: ____________________
Processed by: ____________________
Revised on 5/10/2016
Seahawk Fitness
Personal Training
Exercise History and Attitudes Questionnaire
In the past six months, how often have you been engaged in physical activity?
 Regularly (3 to 4 times/week)
 Semi-regular (1 to 2 times/week)
 Sporadic (1 to 2 times/month)
 None
Do you have any negative feelings toward, or have you had any bad experiences with, physical activity
programs including specific experiences at the SRC?
 NO
 YES
If yes, please explain ________________________
Circle the number that corresponds to the response which best describes you for each of the following
statements (1= low ability/interest, 5 = high ability/interest).
Importance of competition during exercise.
1
2
3
How hard do you like to be pushed or motivated during exercise?
1
2
3
Present cardiorespiratory fitness.
1
2
3
Present muscular fitness.
1
2
3
Present flexibility.
1
2
3
4
5
4
5
4
5
4
5
4
5
Do you start exercise programs but then find yourself unable to stick with them?
 NO
 YES
Are you currently involved in regular cardiorespiratory exercise?
 NO
 YES
If yes, specify the type of exercise_____________________
Minutes per day _______
Days per week _______
Are you currently involved in regular strength training exercise?
 NO
 YES
If yes, specify the type of exercise_____________________
Minutes per day _______
Days per week _______
Rate your perception of the exertion of your exercise program (circle the number):
(1) Light (2) Fairly light
(3) Somewhat hard
(4) Hard
Page 3 of 9
Seahawk Fitness
Personal Training
What other exercise, sport or recreational activities have you participated in the last
six months?_________________________________________________________
Minutes per day _______ Days per week _______
Please list any cardiorespiratory activities you enjoy: ______________________
Please list any strength training activities you enjoy: ______________________
How many meals and/or snacks do you have per day? _____________________
Do you feel you eat healthy most of the time?
 YES
 NO
If no, why not? _________________________________________
How many glasses of water do you drink per day?
 0-2
 3-5
 6-8
 9-12
 more then 12
What are your personal barriers for not exercising or sticking to an exercise program?
_____________________________________________________________________
Why have you decided to begin or improve you exercise program? _______________
_____________________________________________________________________
Why have you decided to hire a personal trainer?
 Need motivation and accountability
 Improve physical fitness
 Weight loss/management
 Improve strength
 Post rehabilitation training
 Boredom with current exercise program
 Want to learn more about fitness
 Training for a specific event
 Other: __________________________
Specifically describe what you would like to accomplish through your fitness program during the next:
a. 1 month ______________________________________________________
b. Semester ______________________________________________________
c. Academic year_________________________________________________
Page 4 of 9
Seahawk Fitness
Personal Training
How likely are you to exercise when you are not with your trainer?
Scale of 1 to 5 (1 = not likely, 5 = very likely): ___________
How much time are you willing to devote to an exercise program?
Minutes per day _______ Days per week _______
Please list any other considerations or information your trainer should be aware of before getting started? (ex:
medications, supplements, injuries, exercise or activities you can't/won't perform, effective motivation
techniques for you, etc.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Goal Setting
Setting specific, measurable, attainable, relevant, timely goals will be something you and your trainer will do
together in order to assure that you get the most out of each session. When choosing goals they should be
S.M.A.R.T.
Specific - If your
amount
of
body fat %).
Specific
goal is weight loss; try to make it more specific. Try stating the
weight, the time frame, and the method of measurement (scale or
Measurable - To
way you look is
Measureable
truly evaluate improvements, the goal should be measurable. The
not tangible, and could be frustrating to evaluate.
Attainable
you are allowing
Attainable
Goals should be challenging but possible. Keep in mind how long
for reaching your goal and make sure that is safe and realistic.
Relevant - Goals
Timely - Set a
Please list three
should be pertinent to your interest, needs, and abilities.
Realistic
Timely
timeline reaching your goal. Again be realistic.
fitness goals. This will help your training understand your needs.
1.____________________________________________________
2.____________________________________________________
3.____________________________________________________
Page 5 of 9
Seahawk Fitness
Personal Training
Medical History Information
Emergency Contact Information:
Name: ______________________________ Phone: __________________ Relationship: ________________
Please indicate if any immediate family member has or has had any of the following:
 Heart Attack (Mother/Father)
 Stroke (Mother/Father)
 Cardiovascular Disease (Mother/Father)
 High Blood Pressure (Mother/Father)
 High Cholesterol (Mother/Father)
 Diabetes (Mother/Father)
 Obesity (Mother/Father)
 Cancer (Mother/Father)
 Osteoporosis (Mother/Father)
Please indicate if:
 Father has passed away prior to age 55 due to a cardiovascular event
 Mother has passed away prior to age 65 due to a cardiovascular event
Do you smoke cigarettes?
 Never
 Current
Packs/day: ____
 Quit
Date: ____
No. of years: ____
Do you use other forms of tobacco?
 None
 Pipe
 Cigar
 Snuff
 Chew
Do you currently drink alcohol?
 NO
 YES No. of drinks/week: ___
Please list any medications that you are currently taking. Please list medication, dose and reason.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________
Page 6 of 9
Seahawk Fitness
Personal Training
Please list any known allergies and your reaction to the allergy. ________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please indicate you if you are currently or have in the past experience any of the following. Please include
comments regarding date of the incident and precautions you are taking.
 Unexpected weight loss/gain
 Chronic fatigue
 Change in appetite
 Chest pain/pressure
 Leg pain with exercise
 Rapid or irregular heart beat
 Chronic joint or muscle pain
 Back pain
 Bone joint or muscular injury
 Arthritis or rheumatic condition
 Bursitis
 Persistent headache
 Fainting, dizziness, or light headedness
 Memory loss
 Numbness
 Obesity
 Thyroid disease
 Diabetes
 Hypoglycemia (low blood sugar)
 Heart attack
 Stroke
 High cholesterol
 High blood pressure
 Cancer
 Epilepsy
 Eating disorder
 Surgical disorder
 Pregnancy (now or within last 3 months)
Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
Page 7 of 9
Seahawk Fitness
Personal Training
Physical Activity Readiness Questionnaire (PAR-Q)
Regular fitness activity is fun and healthy, and increasingly more people are starting to become more active every
day. Being more active is very safe for most people. However, some people should check with their doctor before
they start becoming much more physically active. Complete the seven questions in the box below to specify if you
need medical clearance from your physician before starting exercise.
Please read the questions carefully and answer honestly. Circle YES or NO.
YES
NO
Has your doctor ever said that you have a heart condition and that you should only do
physical activity recommended by a doctor?
YES
NO
Do you feel pain in your chest when you do physical activity?
YES
NO
In the past month, have you had chest pain when you were not doing physical activity?
YES
NO
Do you lose your balance because of dizziness or do you ever lose consciousness?
YES
NO
YES
NO
YES
NO
Do you have a bone or joint problem that could be made worse by a change in your
physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered YES to one or more questions:
 Talk with your doctor by phone or in person BEFORE you start becoming much more physically active
or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you
answered YES to.
 Have you physician fill out a Medical Release Form providing as much information about contradictions,
restrictions, and advice for your exercise program.
If you answered NO honestly to all PAR-Q questions:
 Become more physically active-begin slowly & build up gradually. This is the safest & easiest way to go.
 Sign up for a fitness assessment to learn about your current fitness levels and to assist in goal setting.
Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or
health professional. Ask whether you should change you physical activity plan.
Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, UNCW Campus
Recreation, and their agents assume no liability for persons who undertake physical activity, and if in doubt after
completing this questionnaire, consult your doctor prior to physical activity.
I have read, understood, and completed this questionnaire. Any questions I had were answered to my full
satisfaction.
__________________________________________________________________________________
Name
Signature
Date
__________________________________________________________________________________
Signature of Parent or Guardian
Witness
Page 8 of 9
ASSUMPTION OF RISK
(BINDING LEGAL DOCUMENT -- READ CAREFULLY BEFORE SIGNING)
Recreational activities and athletic programs involve substantial risks of bodily injury, property damage, and other dangers
associated with participation in such activities. Dangers related to such activities may include but are not limited to:
hypothermia, broken bones, strains, sprains, bruises, drowning, concussion, heart attack, heat exhaustion, injuries associated with
travel, and death.
I acknowledge that I am aware that there are risks, hazards, and dangers inherent in such activities and in the training, preparation
for, and travel to and from such activities. I further acknowledge that it is my sole responsibility to participate only in those
activities for which I have the prerequisite skills, qualifications, preparations, and training.
I acknowledge that University of North Carolina Wilmington does not warrant or guarantee in any respect the competency or
mental or physical condition of any trip leader, instructor, vehicle driver, or individual participant in any athletic or recreational
activity. I further acknowledge that University of North Carolina Wilmington makes no warranty as to the condition, safety, or
suitability of any equipment, vehicle, property or premises for any purpose. All participants in voluntary recreational activities
and athletic programs are required to sign this Release, Waiver of Liability and Covenant Not to Sue form.
I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage
sustained through my participation in such voluntary athletic or recreational activities. I acknowledge that University of North
Carolina Wilmington does not provide insurance coverage for me.
I understand that, upon request, I will be provided with a copy of this document, which I have read and understand. I accept and
assume all risks, hazards, and dangers involved in such activities in which I may elect to participate, including the training,
preparation for, and travel to and from the site of such activities.
_______________________________________________________________________________________________________
Printed Name
Signature
RELEASE, WAIVER OF LIABILITY AND COVENANT NOT TO SUE
(BINDING LEGAL DOCUMENT -- READ CAREFULLY BEFORE SIGNING)
I hereby agree that for the sole consideration of University of North Carolina Wilmington allowing me to participate in voluntary
recreational programs or athletic activities and in connection therewith, making available to the undersigned for my use while
participating in such programs or activities, certain equipment, vehicles, facilities, grounds, or personnel of the Institution, I do
hereby waive liability, release and forever discharge University of North Carolina Wilmington, its members individually, and its
officers, agents, and employees, and the North Carolina State Tort Claims Trust Fund, of and from any and all claims, demands,
rights, and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily
and personal injuries, damage to property, and the consequences thereof, including death, resulting from my voluntary
participation in or in any way connected with such recreational programs and athletic activities, including without limitation
travel.
I further covenant and agree that for the consideration stated above I will not sue University of North Carolina Wilmington, their
members individually, its officers, agents, or employees, or the North Carolina State Tort Claims Trust Fund, for any claim for
damages arising or growing out of my voluntary participation in recreational programs or athletic activities at or in conjunction
with University of North Carolina Wilmington
I understand that the acceptance of this release, waiver of liability, and covenant not to sue University of North Carolina
Wilmington, or the North Carolina State Tort Claim Trust Fund, shall not constitute a waiver, in whole or in part, of sovereign,
governmental, or official immunity by said Board, its members, officers, agents, and employees.
Further, I understand that this release, waiver of liability, and covenant not to sue shall be effective during the entire period of my
enrollment or employment at the Institution.
I certify that I am over 18 years of age and suffering under no legal disabilities and that I have read the above carefully before
signing. I understand that I may have a copy of this document if I request it.
This _________ day of ______________________, 20__
UNCW I.D #: _____________________________________
Print Name: _____________________________ Signed in the presence of: ______________________________
Signature: ___________________________________________
Page 9 of 9