Small Group Training Renewal Form

Name Name First Last
Date Date / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
CWID
OSU Affiliation

OSU Affiliation Undergraduate Student Graduate Student Medical Student Resident Faculty/Staff Other
Which campus would you like to receive personal training?

Which campus would you like to receive personal training? Tahlequah-CN CHS-Tulsa
Method of Payment

Method of Payment Cash Check Bursar (Student Only)
Emergency Contact Information
Name Name First Last
Relationship
Phone Phone - ### - ### ####
Email
Participants

Please list the other participants in your small group
Name 1 Name 1 First Last
Name 2 Name 2 First Last
Name 3 Name 3 First Last
Name 4 Name 4 First Last
Name 5 Name 5 First Last
How many sessions would your group like to purchase?
Do you prefer working with a male or female trainer?
If you prefer a particular trainer, please specify
Would you prefer to meet with your trainer 1x/week, 2x/week, or 3x/week?
Would you prefer Virtual Training?

Would you prefer Virtual Training? Yes No
Availability

Please mark days and times that you ARE available to meet with a trainer.
Prefer Day Prefer Day / MM / DD YYYY
Prefer Time

Prefer Time Morning Noon Afternoon
Fitness History and Goals

(Please be as detailed as possible)
1. When was the last semester you participated in small group training?
2. Do you plan to exercise in addition to personal training sessions?

2. Do you plan to exercise in addition to personal training sessions? Yes No
3. What primary health goals would you like your program to focus on?

3. What primary health goals would you like your program to focus on? Weight loss Cardiovascular Endurance Muscular strength Flexibility Muscular Endurance Balance/Stability Other
4. Please specify any forms of exercise you know you cannot do.
5. Do you smoke or have you quit smoking in the last 3 months?

5. Do you smoke or have you quit smoking in the last 3 months? Yes No
6. Do you have a hernia/other condition that could be aggravated by lifting weights?

6. Do you have a hernia/other condition that could be aggravated by lifting weights? Yes No
7. Are you currently pregnant or less than 3 months postpartum?

7. Are you currently pregnant or less than 3 months postpartum? Yes No
8. Have you had any health changes since filling out your initial paperwork?

8. Have you had any health changes since filling out your initial paperwork? Yes No
If yes, please describe
Cancellation Policy: The client must notify the trainer at least 24 hours prior to the session if he/she wishes to cancel or reschedule. If the client does not notify the trainer at least 24 hours prior to the session, he/she may knowingly forfeit that session and will not be eligible for a refund.

Expiration Notice: All small group training sessions will expire one year from date of purchase. If the client does not use all of their sessions within that year, he/she knowingly forfeits the remaining sessions and will not be eligible for a refund.

Refund Policy: Small Group training sessions are NON-REFUNDABLE.

Release and Indemnity Agreement: I hereby release the Board of Regents at Oklahoma State University and all its employees from all claims on account of injury which may be sustained while participating in this program, and I agree to indemnify the Board of Regents of Oklahoma State University and its employees for any claim which may hereafter be presented as a result of such injuries.
Name Name First Last
Date Date / MM / DD YYYY
Please check this box if you agree to and understand all information stated above

Please check this box if you agree to and understand all information stated above I understand and agree

Small Group Training Renewal Form

Small Group Training Renewal Form

Emergency Contact Information

Participants

Availability

Fitness History and Goals