My Information Name * Please tell us your first and last name UO ID# Please provide us with your UO 95# Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Please provide us with your date of birth. Phone Number * Please provide us with a contact phone number E-mail * Please provide us with your contact e-mail. Gender Identity Optional: If you would like to tell us your gender identity, please tell us how you identify. How do you prefer to be contacted? * Email Text Phone Call Choose your package * All new personal training clients are required to begin with the initial training package. Fitness Assessment ($30 for 60 minutes) Body Composition ($20 for 15 minutes) Initial Training Package ($55, two 60-minute sessions) Buddy Training Package ($55, two 60-minute sessions) Frequency * How many times per week do you want to meet with a trainer? What days and times do you prefer? * Indicate your preferred times, but listing all times you are able to train will help expedite being matched with a trainer. Do you have a specific trainer on staff you would like to work with or other staff requirements of your trainer? Would you prefer video training over in-person training? * Yes No Do you have any health concerns that may inhibit your training sessions? * Yes No If yes is checked, a follow up health history questionnaire will be sent to you that must be completed prior to training. Please briefly explain your exercise history and current physical activity. What are your primary reasons/goals/objectives for seeking a personal trainer? Do you have any special needs? Who referred you to this program?