Total Athlete Training Registration - Winter 2021/2022 Student InformationStudent Name First Last Student Nickname Student Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Cell Number(Required)Student's Grade (2021-2022)(Required) Student's Gender Student's Shirt Size (Adult S/M/L/XL) Student's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student's Sport(s) Baseball Basketball Cross Country Dance Football Golf Gymnastics Hockey Lacrosse Soccer Softball Track and Field Volleyball Wrestling Other Parent/Guardian InformationParent/Guardian Name First Last Parent/Guardian Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent Email Address Parent Cell NumberEmergency Contact Name First Last Emergency Contact Relationship Emergency Contact PhonePar-Q and Medical HistoryPhysical Activity Readiness Questionnaire1. Has a doctor ever said your child has a heart condition and that he/she should only perform physical activity recommended by a doctor? Yes No 2. Does your child feel pain in his/her chest when performing physical activity? Yes No 3. In the past month, has your child had chest pain when NOT performing physical activity? Yes No 4. Does your child lose his/her balance because of dizziness or does he/she ever lose consciousness? Yes No 5. Does your child have a bone or joint problem that could be made worse by a change in his/her physical activity? Yes No 6. Is your child’s doctor currently prescribing any medication for blood pressure or a heart condition? Yes No 7. Do you know of any reason why your child should not engage in physical activity? Yes No 8. Please tell me about any pain or injuries your child has experienced or currently experiences in the ankle, knee, hip, back, elbow, shoulder or neck. If none, please state so.9. Please let me know of any surgeries your child has had. If none, please state so.10. Has a medical doctor ever diagnosed your child with a chronic disease? If yes, please explain.11. Please list any medications and purpose.WaiverI understand that I am purchasing group training sessions (Total Athlete Training) for my child and must read, agree to and sign this agreement where I assume the risks for participation, waive of liability, and Total Athlete Training policies and procedures. I understand that the program is voluntary and that a Certified Personal Trainer will develop and guide my child through an exercise program. I represent that I will complete the PAR-Q and any other health history form accurately and completely on behalf of my child including disclosure of any prescribed medications he/she is taking and any exercise or diet limitations I am aware of or have been informed of by my child’s doctor. During the program if my child’s medications, condition, or medical limitations should change, I will notify the Trainer. I understand that it is recommended that my child have a yearly physical or more frequent physical examination and consultation with his/her physician as to physical activity and diet so I am aware of what is appropriate for my child. I acknowledge that my child either has had a physical exam and has been given a physician’s permission to participate or I have decided to allow my child to participate without approval of a physician. I understand that a Trainer will review my child’s PAR-Q and any other health history form but that a Trainer is not a physician and cannot replace the advice and expertise of a qualified physician. I understand that I have the complete right to stop or decrease my child’s exercise at any time during a session and that it is my and my child’s obligation to inform the Trainer of any symptoms such as fatigue, shortness of breath or chest discomfort. I realize that participation in an exercise training program includes but is not limited to exercising, use of exercise equipment and strenuous exertion (such as strength training or high intensity aerobic activity) which will increase heart rate and body temperature. I understand that exercise involves certain risks, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack, stroke or even death. Also, injuries could occur to bones, joints or muscles. Slips, falls, and unintended loss of balance could result in muscular, neurological, orthopedic or other bodily injury. I understand that part of the risk involved in undertaking any activity or program is relative to my child’s own state of fitness or health (physical, mental, or emotional) and to the awareness, care and skill which my child conducts himself/herself in that activity or program. I understand that proper form of any exercise (as described and/or demonstrated by Trainer) performed by my child is a necessary and essential component of an exercise program. Knowing the material risks and knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of possible death, which could occur by reason of my child’s participation. I do hereby waive, release and forever discharge Total Strength Fitness and the Total Athlete Training program from any and all responsibilities or liability for any present and future injuries or damages resulting or arising from my child’s participation in any activities including but not limited to exercise, group training, or use of the equipment used within Total Athlete Training. I also understand that Total Athlete Training may take place in a facility not owned by Total Strength Fitness, and this facility may have its own equipment not used by Total Athlete Training. I understand that my child will not use any equipment not included in the Total Athlete Training program during the time that he/she is participating in that program. I AGREE AND UNDERSTAND.(Required) Initial Here.Personal Training Policies and Procedures1. Total Athlete Training sessions are purchased upfront and in their entirety. 2. Total Strength Fitness does not offer refunds for unused sessions by client. 3. PAR-Q, Physician Approval (if applicable), and Total Athlete Training Agreement must be completed, signed, and on file prior to the beginning of the first session. 4. Training sessions will begin promptly at the time specified by Total Athlete Training and end 90 minutes, or other agreed upon amount of time, from that specified time. 5. I will make certain that my child arrives to training prior to the start of each training session and that my child will have a way home from training upon the immediate end of each training session. I AGREE AND UNDERSTAND(Required) Initial HereParent/Guardian AgreementI declare that I have read, understand and agree to the contents of this Total Athlete Training Agreement in its entirety. I understand that the Assumption of Risk, Waiver of Liability, and Total Athlete Training Policies and Procedures are intended to be as broad and inclusive as permitted by the State of Minnesota and agree that if any portion is held invalid, the remainder will continue in full force and effect. Signature(Required)Please provide signature via touchscreen, touchpad or mouse.PaymentOnce you click submit, you will be directed to PayPal for payment. Payment will be accepted via PayPal funds, eCheck or Credit Card. If you choose to pay by check, instructions will be provided on where to send your payment.Total Registration FeePayment MethodPayPalPersonal CheckPost Title PhoneThis field is for validation purposes and should be left unchanged.
