Personal Training Intake Form

Indicates required field

First Name

Last Name

Age

Phone Number

Email Address

Which service are you inquiring about?

(e.g. Team Training, Inbody, etc.)

What are your primary fitness goals, and in what timeframe would you like to achieve them?

What are your favorite activities or sports?

Rank your current fitness level on the following scale

Identify numbers 1 through 10, where 1 is lowest value

Rank the following goals in order of importance, with 1 being the most important and 8 being least important.

Questions	1	2	3	4	5	6	7	8	9	10
Improve health	1	2	3	4	5	6	7	8	9	10
Improve endurance	1	2	3	4	5	6	7	8	9	10
Improve strength	1	2	3	4	5	6	7	8	9	10
Fat loss	1	2	3	4	5	6	7	8	9	10
Muscle mass	1	2	3	4	5	6	7	8	9	10
Increase power	1	2	3	4	5	6	7	8	9	10
Weight gain	1	2	3	4	5	6	7	8	9	10
Sport specific	1	2	3	4	5	6	7	8	9	10

Please provide the sport or athletic event for which you are training

What current barriers are holding you back from reaching your goals?

How often do you workout now?

How many times each week do you do resistance training?

How many times each week do you do cardiovascular training?

Please list any health issues below

Please list any injuries below

Please provide your training availability

The personal information that you provide to Red Deer Polytechnic is collected under the authority of the Freedom of Information and Protection of Privacy (FOIP) Act - section 33(c).

The information will be used for the purpose of processing your personal training request.

Collected personal information is protected from unauthorized access, collection, use, and disclosure in accordance with the FOIP Act and can be reviewed upon request subject to the provisions under the Act.

Questions regarding the collection of personal information, or other information about the administration of the Freedom of Information and Protection of Privacy Act can be directed to the Access & Privacy Coordinator Red Deer Polytechnic, 100 Donald Boulevard, Box 5005, Red Deer, Alberta, T4N 5H5, or email.