Personal Trainer Request Form

Page 1 of 3 - PERSONAL INFORMATION

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Full Name
Gender

Gender Female Male Preferred Preferred

Knowing gender assists the trainer in designing a program for the client based on sex specific hormones estrogen and testosterone implicated in muscle growth, fiber size and contractile function. *if you are taking hormone therapy please discuss with your trainer
Phone Phone - ### - ### ####
Email
Are you a resident or non resident of BWG

Are you a resident or non resident of BWG Resident Non Resident
Age
Best time to call Best time to call : HH MM AM/PM
Notice of Collection

All personal information on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act and Municipal Act, 2001 and will be used for the purposes of personal training request. Questions regarding this collection may be directed to the Clerk, 905-775-5366, 100 Dissette Street, Unit 7 and 8, Bradford, ON L3Z 2A7.
How would you rate your current level of fitness?

How would you rate your current level of fitness? Inactive Moderate Active Very Active
What activities have you participated in during the past 6 months?
What are your goals?

What are your goals? Lose weight Lose inches Burn fat Gain weight Gain muscle mass Reduce BP Increase energy Reduce stress Improve overall health Sport specific Other Other
Do you have any injuries, surgeries or any medical concerns that could affect exercise?

Do you have any injuries, surgeries or any medical concerns that could affect exercise? No Yes (please explain) Yes (please explain)
Please indicate how many sessions you are interested in
Please indicate your availability (check all available times)

Please indicate your availability (check all available times) Early AM (6 - 9am) Mid AM (9 - 12pm) Afternoon (12 - 4pm) Evening (4 - 9pm)
Please write any other information you feel is important for us to know to assist you in reaching your health and fitness goals.
The BWG Fitness Programmer will be in contact with you within 48 hours.

Personal Trainer Request Form

Personal Trainer Request Form

Page 1 of 3 - PERSONAL INFORMATION

Notice of Collection

The BWG Fitness Programmer will be in contact with you within 48 hours.