Welcome! I am delighted that you chose to work with me as a part of your commitment to health and fitness. I’m here to provide you with the necessary information and motivation to help you reach and maintain your personal fitness goals. The following information will provide you with important program policies. Before getting started, please read and these Policies so that I can be sure that you have been provided with and understand this information.

Full Name*

Email*

Address*

City*

State*

Zip Code*

Date of Birth (MM/DD/YYYY)*

Gender*

Cell Phone*

Home Phone

Emergency Contact



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2B Personal Training & Coaching Policies:

• Coaching and Training sessions will begin promptly at the time specified by coach and/or trainer. Payment will be made prior to session. Please be on time in order to make full use of the training session.
Cancellations: In order to cancel or reschedule an appointment, you must contact me at least 24 hours in advance of the scheduled appointment or you will be charged for that session and/or class. (NOTE: any exception to this policy will be made purely at the discretion of the trainer.) Similarly, if I do not contact you at least 24 hours in advance to cancel or reschedule an appointment, you will receive one complimentary session.
• All clients are encouraged to be prompt. If the client is more than 5 minutes late, the “5 minute rule” takes effect where the session will start and this time will be deducted from it. If possible, the trainer will attempt to complete the entire session if the schedule allows it. If the coach and/or trainer arrives late, the amount of time will be added for an extended session. Please be advised that after waiting 15 minutes for a scheduled client, the session is subject to cancellation and clients will be charged for a full session.
• I do not offer refunds or credits, so please be sure that my services will match your needs before committing through payment. If you find that your needs change once you have begun this program, please let me know; I am willing to find a solution to accommodate your coaching and/or training needs.
Injury: You are fully responsible for any injury you incur before, during, or after workouts. The coach and/or trainer will not be held accountable in any manner, legal or otherwise. Any injury incurred before, during, or after workout sessions is solely the responsibility of the client. Focusing during your workout and following directions will help prevent any injury. It’s the client’s responsibility to communicate any symptoms or discomfort during the session.
• No verbal agreement can alter or change the conditions of this agreement in any part.


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Release, Covenant Not to Sue, and Waiver

I, *, do hereby consent to participate in a personal training program that will include weight training and/or cardiovascular exercise. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses, and, in rare instances, heart attack or death. Every effort will be made to minimize these risks. Any information that is obtained regarding my fitness level and my progress will be treated as privileged and confidential and will not be released or revealed to any person other than my physician without my expressed written consent. I have read and understand the foregoing consent to participation in said program. I am aware that I may discontinue participation in the program at any time that I see fit to do so. If at any time I have questions concerning the content, policies, or procedures regarding the personal training program I will discuss these questions with my coach and/or trainer immediately.
In addition, I agree to the following:
a) Assume all risk of injury and all risk of damage to or loss of property arising out of my participation in this program.
b) Release, discharge, and waive any and all responsibility for Scott Welle, 2B Consulting, Run M5, or any other affiliated program (These Companies), and any other coach and/or trainer representing These Companies from and against any liability of injury, including death, and for damage to or loss of property which may be suffered by the undersigned arising out of, or in any way connected with the participation in this program.
c) Indemnify and hold These Companies, and any other coach and/or trainer representing These Companies harmless from and against all liability, claims, demands, actions, loss, and damage arising out of my participation in said personal training & coaching program.
d) Consent to use my video, photograph or audio tape regardless of whether these materials are used for fundraising, advertising, publicity, marketing, or any other commercial purposes on behalf of These Companies. I also waive claims to compensation or damages based on the use of my image or voice, and waive rights to inspect or approve the finished photograph, video or audio tape.

By signing below, the undersigned hereby acknowledges that he/she has read the above carefully before signing, and agrees to comply with all the above.

Signature*
Date (MM/DD/YYYY)*

Signature of Parent/Guardian if participant is 17 years old or younger:

Signature
Date (MM/DD/YYYY)



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The Physical Readiness Questionnaire – PAR-Q

Regular physical 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.

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor first.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
2. Do you feel pain in your chest when you do physical activity?*
3. In the past month, have you had chest pain when you were not doing physical activity?*
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
6. Is your doctor currently prescribing drugs for your blood pressure or heart condition?*
7. 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.
• You may be able to do any activity you want –as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
• Find out which community programs are safe and helpful to you.

If you answered NO honestly to all PAR-Q question, you can be reasonably sure that you can:
• Start becoming much more physically active –begin slowly and build up gradually. This is the safest and easiest way to go.
• Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

PLEASE NOTE: If your health changes so that you have to answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
I have read, understood and completed this questionnaire.

Signature*
Date (MM/DD/YYYY)*


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Health History Form

Are you taking any medication or drugs? If so, please list medication, dose and reason:*

Does your physician know you are participating in this exercise program?*

Describe any physical activity you do somewhat regularly:*

Do you now, or have you had in the past:

1. History of heart problems, chest pain or stroke*
2. High or low blood pressure*
3. Any chronic illness or condition*
4. Difficulty with physical exercise*
5. Advice from physician not to exercise*
6. Recent surgery (last 12 months)*
7. Pregnancy (now or within last 3 months)*
8. History of breathing or lung problems*
9. Muscle, joint or back disorder*
10. Previous injuries not fully healed*
11. Diabetes or thyroid conditions*
12. Cigarette smoking habit*
13. Obesity (more than 20% over ideal body weight)*
14. HIV*
15. History of heart problems in immediate family*
16. Hernia, or any condition that my be aggravated by lifting weights*

Other Comments:



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Exercise History and Attitude Questionnaire

1. Do you have any negative feeling toward, or have you had any bad experiences with physical activity programs?*

If Yes, please explain:

2. Do you have any negative feelings toward, or have you had any bad experiences with fitness testing and evaluation?*

If Yes, please explain:

Rate yourself on a scale 1 to 5 (5 indicating very high). Choose the number that best applies.

• Characterize your present athletic ability:*
• When you exercise, how important is competition?*
• Characterize your present muscular (strength) capacity:*
• Characterize your present flexibility capacity:*
• Characterize your present aerobic (cardiovascular) capacity:*

3. Do you start exercise programs but then find yourself unable to stick with them?*

If Yes, please explain:

4. How much time are you willing to devote to an exercise program?*
• Minutes/Day
• Days/Week

5. Are you currently involved in regular endurance (cardiovascular) exercise?*

If Yes, please indicate:
• Type of Exercise
• Minutes/Day
• Days/Week

6. What other exercises, sport or recreational activities have you participated in?*

7. What is your ideal time to exercise?*


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Goals, Expectations and Purpose

Use the following scale to rate each goal separately. Circle the appropriate number:
(1 = Not Important, 5 = Somewhat Important, 10 = Very Important)

1. Improve cardiovascular fitness*
2. Body-fat weight loss
3. Reshape or tone my body*
4. Improve performance for specific sport*
5. Improve moods and ability to cope with stress*
6. Improve flexibility*
7. Increase strength*
8. Increase stamina and energy level*
9. Feel better*
10. Enjoyment*

By how much would you like to change your current weight (please be as specific as possible)?*

Personal Statement Of Purpose:

I am entering this coaching and/or training program because I want to:*

Expectations Of Coach and/or Trainer:

I have the following expectations of my coach and/or trainer:*



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Additional Information: