Please answer the following questions and click "submit" when finished. Upon submission, your questionnaire will be sent to the Fitness Coordinator and a trainer will contact you within 2-3 business days.
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Please let us know your name.
Please let us know your name.
Please enter your phone number with area code.
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Please let us know your email address.
Please let us know your message.
Please let us know your message.
Please let us know your message.
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Medical Health Status Questionnaire - On this portion of the form, a number of questions regarding your physical health are to be answered. Please answer every question as accurately as possible so that a correct assessment can be made. Please place a tick in the space to the left of the question to answer "Yes." Leave blank if your answer is "No." Please ask if you have any questions. Your responses will be treated in a confidential manner.
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Do you drink alcoholic beverages? How many units of alcohol do you consume each week? Units Chart: 1/2 pint of beer = 1 1 glass of wine = 1 1 pub measure of spirits (gin, vodka, etc.) =1 1 can of beer = 1.5 1 bottle of strong lager = 2.5 1 can of strong lager = 4 1 bottle of wine = 7 1 litre bottle of wine = 10 1 bottle of fortified wine (port, sherry, etc.) = 14 1 bottle of spirits = 30
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Please tell us more about your exercise patterns and goals:
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Please use the space below to record 3 concrete commitments that you are willing to make to your own health goals. These should be challenging but also realistic and attainable commitments.
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Please check ALL times you could be available to train:
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Current Symptoms: Please review the following questions regarding Location, Severity, Onset and Duration to your pain or body limitations:
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I wish to participate in the exercise and training program offered by the Eagan Community Center (ECC). I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her written approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. I agree that the ECC shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, outdoors, or at a corporate , commercial, residential or other fitness facility) and I expressly release and discharge the City of Eagan/ECC, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and assigns.
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I certify that the answers to the questions outlined on the ACSM Health Status Questionnaire are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “yes” to questions indicating potential risk factors. I understand and agree that it is my responsibility to inform my Fitness Specialist 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.
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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 Fitness Specialist.
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understand the results of any program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.
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I understand that all posture alignment training rates are based on 60 minute sessions and should I arrive late, there is no guarantee I will receive the full session with my trainer. In return, if my Trainer is late for a session, I will still receive the full session time.
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I understand that the ECC bills its clients on a pre-pay basis. Once my Fitness Specialist and I have decided upon the number of sessions I will purchase, payment must be made before the sessions are conducted. I understand that all training sessions are non-transferable and non-refundable. I also understand that all training sessions must be redeemed within 1 year of purchase.
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I understand that the ECC operates on a scheduled appointment basis and thus, requires that I provide 24 hours notice when cancelling 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. I understand that should I arrive late for a scheduled session that the session will end according to the pre-arrange scheduled time.
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I understand that when working with a trainer as a small group that a spokesperson for the group must provide 24 hours notice when cancelling an appointment which would apply for the entire group. Any member(s) of a group who are not present for a planned training session will be charged for that session.
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I understand that during a training session, my posture alignment trainer 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 my posture alignment trainer discontinue using this technique.
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I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by my posture alignment trainer.
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I understand that should my posture alignment trainer become ill or is away on holidays, I may request another trainer to be assigned to me so that my fitness progress does not suffer. I also understand that in the event that my posture alignment trainer is no longer employed by the ECC, a suitable trainer will be re-assigned to oversee my program and workout sessions.
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