This action might not be possible to undo. Are you sure you want to continue?
Thank you for choosing to take advantage of Talisman Centre’s Personal Training services. We have a variety of services designed to meet your individual needs. For ongoing guidance, progression and support we suggest you choose from 4, 8, or 12 private personal training sessions. Get the complete experience by purchasing a Fitness Assessment or a Nutrition Analysis to complement your fitness training. Details of these options can be found in a Talisman Centre program brochure, or by calling 355-1287.
I, ___________________________ declare that I intend to use some or all of the activities, facilities, programs and services (herein after called “Activities”) offered by the Talisman Centre. I understand that different people have different capacities for participating in the various Activities offered at Talisman Centre. I assume full responsibility during and after my participation in such Activities and for my choices to use or apply at my own risk, any portion of the instruction or guidance that I receive while participating in these Activities. I understand that the risk involved in undertaking any of the Activities is related to my own state of fitness or health, and the awareness, care and skill with which I conduct myself in any of the Activities of Talisman Centre. I also understand that I am free to withdraw from, reduce or modify my involvement in any of the Activities and I realize that I should do so on recognition of any signs of physical discomfort. I further understand that the possible risks involved in participating in these Activities may include muscle, tendon, ligament, bone and joint soreness; muscle, tendon, and ligament strain, tear or rip; bruising, death; skin laceration; tears, cuts or punctures; shortness of breath, dizziness, fainting, or unconsciousness; tightness in chest, bone breaks, discoloration, separations or fractures; fatigue; sweating; eye punctures; heart attack or stroke; aggravation of an existing or past injury; discomfort or problem with any other injury; discomfort or physical problems associated with physical activity, and many other forms of physical discomfort. I have read the above list of possible risks associated with my participation in the Activities offered by the Talisman Centre for sport and wellness. __________ (Initial) I consent to taking all of the above noted risks by VOLUNTARILY PARTICIPATING in the Activities of Talisman Centre. __________ (Initial)
Notice of 24 hours is required by the client and the trainer for any changes to the day or time of the appointment booked and paid for. Appointments not cancelled within a 24-hour notice period by you will not be rescheduled or refunded.
I declare that I have read, understand and agree to the contents of the 24-HOUR CANCELLATION POLICY and the INFORMED CONSENT AGREEMENT in its entirety. Signature: ____________________________ Date: ________________________________ Witness: _______________________________ Date: _______________________________
Name: __________________________________________ Address: _________________________________________ Phone: (H) ______________________________ E-Mail: _____________________________ Physician: _______________________________ Emergency Contact: _______________________ Phone: _________________________ Phone: (H) _________ (W)__________ Age: _____________________ Postal Code: ______________
Please indicate the primary reason for using Talisman Centre’s Personal Training services:
□ Post Physiotherapy Exercise Program (if answered, please see section A below) □ Talisman Centre Weight Loss Program (if answered, please see section B below) □ General Personal Training: (see below and section C below)
Please number the following list of goals priority sequence: o o o o o o o o Improve Cardiovascular Fitness Improve Muscular Endurance Improve Weight Control/Body Composition Improve a Specific Skill Improve Muscular Strength Increase Flexibility Injury Prevention Other (Please List)
A) TALISMAN CENTRE POST PHYSIOTHERAPY EXERCISE PROGRAM
PHYSIOTHERAPIST: CLINIC: PHYSIOTHERAPIST SIGNATURE:
*Prior to the first session with the Rehabilitation Personal Trainer, a referral note and signature from a physiotherapist is required.
1. What in the injury for which you are being treated?
2. What limitations do you have as a result of this injury or any other previous injury?
□ Limited Range of Motion (explain below)
□ Pain or discomfort (explain below)
_____ 3. How often are you going for physiotherapy treatment?
4. Please provide any information with regards to other injuries and current health status which may limit your current ability to be physically active.
5. Are you able to commit to 2 days per week (1 hour per session) for 2-6 weeks with the rehabilitation program? Yes No Preferred appointment day (s) and time(s): _________________________________
TALISMAN CENTRE WEIGHT LOSS PROGRAM
With the assistance of a Personal Trainer, this program will be customized to your needs. Which areas do you need the most help?
□ Workouts/ Program Plan □ Nutrition/ Eating Plan □ Assessing/ Tracking Results
Your weight loss goal is lbs. Your timeline to reach this goal is The Top 3 barriers for you to reach this goal are:
GENERAL PERSONAL TRAINING
1. Please indicate your level of physical activity in the past three months:
□ Occasionally Active
□ Very Active
2. What is your present occupation? How active/mobile are you in your job environment? _______________________________________________________________________ 3. How many days per week can you realistically commit to being physically active? _______________________________________________________________________ 4. How much time do you have for each exercise session? _______________________________________________________________________ 5. How would you rate your current nutritional habits?
□ Usually Good
□ Needs Work
6. Would you consider any of the following:
□ Cooking Class
best service possible.
□ Nutrition Seminar
□ One-On-One Consultation
7. Please provide any additional information that you feel will help us in providing you with the
8. Do you have a preferred trainer? If not list 1 quality you would like your trainer to possess! ____________________________________ Trainer Gender Preference:
□ No preference
Preferred appointment day (s) and time(s): _________________________________ -------------------------------------------------------------------------------------------------Please take the time to complete the PAR-Q form attached, and then return this package, together with payment, to the Service Centre desk. Please note if you have answered yes to one or more questions on the PAR-Q you will need to take the PARmed-X forms attached to your physician for clearance to exercise prior to meeting with a trainer. The Wellness Services Coordinator will review the information you have provided and assign the best trainer to help you to meet your goals. The personal trainer will call you within two business days to book your initial appointment and to answer any questions you may have. Our staff and certified trainers strive to provide excellent customer service by designing highly customized programs to suit your specific & individual needs and goals. We maintain current certifications and pride ourselves on acquiring recent and meaningful information and research to share with our participants. Thank you for choosing the Talisman Centre for Sport and Wellness for all your personal fitness needs. Sincerely,
Sasha Bahador Wellness Services Coordinator Talisman Centre for Sport and Wellness 2225 Macleod Trail South Calgary, AB. T2G 5B6 T: (403) 355-1260 F: (403) 262-1001 www.talismancentre.com firstname.lastname@example.org
Pietra Gall Wellness Services Assistant Talisman Centre for Sport and Wellness 2225 Macleod Trail South Calgary, AB. T2G 5B6 T: (403) 355-1287 F: (403) 262-1001 www.talismancentre.com email@example.com