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Personal Training Assessment Request

First My Name

First Name*

Last Name*

Phone*
First My Date of Birth*
First My Signature*
Second My Name

First Name*

Last Name*
Second My Date of Birth*
Third My Name

First Name*

Last Name*
Third My Date of Birth*
Fourth My Name

First Name*

Last Name*
Fourth My Date of Birth*
Fifth My Name

First Name*

Last Name*
Fifth My Date of Birth*
Sixth My Name

First Name*

Last Name*
Sixth My Date of Birth*
Seventh My Name

First Name*

Last Name*
Seventh My Date of Birth*
Eighth My Name

First Name*

Last Name*
Eighth My Date of Birth*
Ninth My Name

First Name*

Last Name*
Ninth My Date of Birth*
Tenth My Name

First Name*

Last Name*
Tenth My Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Is email your preferable way of contact?
Location Preference*
Central Square
University Park
Trainer Gender Preference*
No Preference
Male
Female

What are your Goals you want to achieve with personal training here at VIM?

What days and times are you available?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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