Personalized Services Consultation Form

Please check one:

Wellness Assessment
Getting Started Package
Private Yoga
Private Pilates Mat / Reformer
Pre / Post Natal Package (ParMed-X form must be completed)
Injury Rehabilitation
Membership Plus
Nutrition Counselling
Life Coaching
Personal Training - # of sessions

First name:

Last name:

Birth date:

 dd/mm/yy

Address:

City:

Province:

Postal code:

Home phone number:

 999-999-9999

Work phone number:

 999-999-9999

Email address:

Best time to phone:

Preferred session time(s):

Are you a member?

Yes No

What would you like to discuss (i.e. goals)?

Are you currently physically active? Please explain.

Do you have a preferred trainer?

CANCELLATION POLICY:
1. With less than 24 hours notice, you will be charged for your missed appointment.
2. It is your responsibility to contact your personal trainer directly to cancel the appointment and reschedule.
**Please Note: All personalized services packages and gift certificates purchased must be completed within one year of purchase date.

INFORMED CONSENT:
I understand that there are potential risks to physical activity, evaluation and testing. I will be working around exercise machines, exercise accessories (e.g. tubing), testing instruments and involved in testing protocols (e.g. step test) and could be exposed to some accidents. I will be participating in exercise activities such as running and weight training and could be exposed to an injury. This could include straining or even tearing muscles, tendons, ligaments, or heart strain even though care will be taken by myself and others to avoid such injury. I will inform the instructor(s) if there are any problems during these tests or activities. (These are the usual risks that are involved with exercise testing and activity.) At any time I may withdraw my consent and terminate my participation in the activities described above. I hereby release and hold harmless the agents, officers and employees of the Vancouver YWCA and affiliated companies, from any liability with respect to me or my property arising out of or connected with my partaking of any programs and courses offered by the Vancouver YWCA. I agree that a Photostat or Faxed copy of this consent and authorization form is accepted as the real document.

Emergency Contact Name:

Phone:

Name of Medical Doctor:

Phone:

Name of Chiropractor:

Phone:

Name of Physiotherapist:

Phone:

Is there anything else we should know about concerning your personal health?

RELEASE FORM:
We advise you that if you are currently taking medication, have any physical ailment or you are otherwise not in physical condition suitable for activity, it could be injurious to you. You should seek medical advice regarding these matters before participating in these programs. THIS DOCUMENT IS A RELEASE OF CLAIMS AND BY SIGNING IT YOU:

1. Acknowledge that when performing exercise routines or engaging in similarly strenuous activity, you may suffer injury.

2. Represent to the YWCA that you are in good health and physical condition and are not disabled, taking medication or suffering from a condition that would prevent you from engaging in such activities or make it potentially dangerous or harmful for you to engage in such activities.

3. ASSUME THE RISK OF AND HOLD THE YWCA HARMLESS FROM ANY LIABILITY FOR ANY PHYSICAL OR OTHER INJURY OR HARM SUFFERED BY YOU DURING OR AS A CONSEQUENCE OF PARTICIPATING IN SUCH PROGRAMS OR PERFORMING SUCH EXERCISE ROUTINES OR ENGAGING IN SUCH OTHER STRENUOUS PHYSICAL ACTIVITY, AND AGREE THAT THE YWCA SHALL NOT HAVE ANY LIABILITY OR RESPONSIBILITY FOR ANY SUCH INJURY OR HARM.
I HAVE CAREFULLY READ, UNDERSTAND, AND AS AN INDUCEMENT TO THE YWCA TO ALLOW ME TO PARTICIPATE IN THE PROGRAMS, AGREE TO THE FOREGOING.

I have read and understood the above informed consent and release of liability.