Pilates

 Private  Session  Policies  and  Procedures  

Welcome:    Thank  you  for  your  interest  in   Pilates  private  sessions  at  Auburn  University.  You  have  taken  the  first  step  
towards  better  overall  health!   We   thank  you  for  allowing   our  Campus  Recreation  Pilates  instructors  to  be  your  
guides.  Our  staff  is  dedicated  to  helping  you  reach  your  goals  by   promoting  healthy,  lifelong  fitness  behavior!    
Before  you  begin   with   your  Pilates  instructor,  please  read  this  packet  in   its  entirety  and  complete  all  applicable  
forms.   These  forms   are  an  important  means  for  us  to  help  you  reach  your  goals  safely  and  effectively.  
Congratulations  on  taking  the  next  step  to  achieving  a  healthier  you!  

Payment  policy:   Campus  Recreation  charges  a  fee  for  services  rendered  by   Pilates  instructors.  All  services  can  be  
purchased  anytime  throughout  the  year  at  the  Campus  Recreation  main  office  located  on  the  3rd   floor   in   the  
Recreation  and  Wellness  Center  or  via  Auburn  University  Online  Payment  Portal.     Payment  must  be  received  before  
sessions  are  scheduled.  Paying  a  Pilates  instructor  directly  is  strictly  prohibited;  all  membership  privileges  will   be  
terminated   immediately.  

Expiration  policy:  Pilates  private  sessions  packages  expire  120   days  from  the  date  of  purchase.  Pilates  
private  sessions   are  void  after  this  time  period.  Pilates  private  sessions  packages  are  non-­‐refundable  (see  
refund  policy)  and  non-­‐transferable.  

Refund  policy:  Pilates  private  sessions  packages  are  non-­‐refundable  except  in   cases  of:  termination   of  
university  employment;  formal  leave  of   absence  and  sabbaticals  (documentation  required);  changes  in   medical  
condition  resulting  in   physical  limitations  (physician  letter  required).  

Late  policy:  If  you  arrive  more  than  15   minutes  late  for  a  scheduled  appointment,  forfeiture  of  the  session  will  
result  and  the  Pilates  instructor  has  the  right  to  leave  the  premises.  All  sessions  are  scheduled  for  60   minutes  
and  end  one  hour  from  the  scheduled   start   time.  

Cancellation   policy:   If  you  must   cancel  or  reschedule   a  private   session,  please  notify   your  Pilates  instructor  by  
phone  and/or  email   at  least   24   hours   in  advance  of  the  scheduled   private  session.  Pilates  private  sessions  not  
rescheduled  or   canceled  at  least  24   hours  in   advance  by   a  client  will   result  in   forfeiture  of  the  session.  

Registration  policy:   The  completed  Pilates  private  session  registration  packet  (along  with   payment)   must  be  
received  before  your  session  is  scheduled  with   a  certified  Pilates  instructor.  The  completed  registration  packet  
can  be  returned  either  by   email  or   t o  the  Campus  Recreation  main  office.  Upon  receipt  of  these  materials,  a  
member  of  our  staff  will   contact  you  via  email  and/or  phone  within   72   hours  to  schedule  your  initial  
appointment.  

**Please  retain  this   page  for   your  records.*  

AUBURN CAMPUS RECREATION PRIVATE PILATES 1

 Medical Health History Questionnaire
This form is not a substitute for a thorough physical examination, assessment, and/or diagnosis by your physician. It is
designed to identify and understand potential issues that may arise due to an increase in physical activity. The Auburn
University Lifetime Wellness & Fitness team strongly recommends that each client undergo a medical examination
before beginning any exercise program. All information provided on this form is personal and confidential and will
not be released to anyone except your referring physician without your written consent. The information you provide
will enable us to better understand you and your health and fitness habits.

Name: Date:

Address:

City: State: Zip Code:

Email Address: @auburn.edu Phone Number:

Date of Birth: Age: Gender: Height: Weight:

Auburn Affiliation: Faculty/Staff Student Fr So Jr Sr Grad Retiree Spouse/Partner

Physicians Name: Phone Number:

Emergency contact: Relationship:

Home phone: Cell Phone:

I. Personal Fitness Goals & Exercise History

1. Please indicate your personal health and fitness goals: (check all that apply)
Better Balance & Mobility

Improve Nutrition

Improve Cardiovascular Fitness

Reshape Body

Enhance Work, recreation & Sports Performance Other:

Please tell us more about your specific short and long term goals for exercise, health, and fitness:

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 2. Exercise history Yes No

Do you currently exercise? If yes, how many times per week?

If no, have you exercised in the past?

Have you ever worked with a fitness professional before?

If you currently exercise, what exercise activities does your workout program include?

II. Signs and symptoms

3. Have you ever experienced any of the following: (check all that apply)

Pain, discomfort, tightness or numbness in the chest, neck, jaw or arms Dizziness or Fainting

Shortness of breath at rest or with mild exertion Ankle Swelling

Difficult, labored or painful breathing during the day or night Rapid pulse or heart rate

Unusual shortness of breath or fatigue with usual activities Claudication (Cramping)

Heart murmur and/or palpitations Back Pain

Severe headaches   Orthopedic problems

If you checked any of the above conditions, you must explain below:

III. Medical diagnoses

4. Have you ever been diagnosed with, or suffered from: (check all that apply)

Heart attack/heart disease Other Cardiac Surgery

Coronary bypass Pacemaker

Stroke Embolism

Aneurysm Angina Pectoris

Angioplasty Phlebitis

If you checked any of the above conditions, you must have medical clearance prior to exercising.
Please give details:

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 5. Have you ever been diagnosed with, or do you have any of the following: (check all that apply)

Chronic bronchitis Peripheral vascular disease

Diabetes Osteoporosis

Osteopenia Emphysema

Asthma Hypertension (>140/90 mmhg)

Thyroid problems High cholesterol (>200 mg/dl)

Emotional disorders Eating disorders

Cancer Swelling of joints

If you checked any of the above conditions, please explain below:

IV. Major risk factors

6. Please answer all of the following questions: Yes No   Unsure
Are you a male over the age of 45 or
Female over the age of 55 who has had a hysterectomy or is postmenopausal?
Has your father or brother experienced a heart attack before age of 55?
Has your mother or sister experience a heart attack before age of 65?
Do you have impaired fasting glucose (diabetes)?

If yes, do you take insulin? What year was the diagnosis?

Do you have high cholesterol (>200ml/dl)?
Has your doctor ever told you that you might have high blood pressure?
Do you currently smoke or have you smoked in the past 6 months?
Do you have a sedentary lifestyle?
If you are a man over the age of 45 or a woman over the age of 55 or if you answered “yes” to two (2) or more of the above
major risk factors, it is recommended that you receive a physician’s clearance before beginning your exercise program.

V. General
7. Please tell us more about you: Yes No

Are you currently pregnant?

Are you currently on a special diet?

Have you had a recent surgery in the past 12 months?

Do you have seasonal allergies and/or hay fever?

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 Do you take ergogenic aids, diet supplements, vitamins, minerals, etc.?
8. Please list any medications you are currently taking including but not limited to prescriptions, allergy medications,
Do you have allergies to any foods or medications?
Medication (supplement): Reason: Dosage:

Medication (supplement): Reason: Dosage:

Medication (supplement): Reason: Dosage:

Medication (supplement): Reason: Dosage:

I understand this medical health history questionnaire has been provided for the purpose of helping me better
understand any potential risks associated with a workout program. I also understand I should share this information
with my physician and seek his or her approval prior to beginning an exercise program. I understand the
information I have provided will be maintained in my personal file for use in case of a medical emergency. My
signature signifies that all of the above is true, to the best of my knowledge. Any information left unanswered was
done so intentionally. If any of the above information changes, i agree to submit these changes in writing to the
coordinator, personal training to update my personal training file.

Participant signature:      Date:

Fitness staff signature: Date:

Staff Use Only Classification: Low Risk Moderate Risk High Risk

Comments: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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 Reset PAR-Q

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 Release and waiver of liability and indemnity agreement
In consideration of being permitted to participate in a fitness assessment, fitness programs, and/
or personal training sessions, which may consist of warm-up, flexibility activities, cardiorespiratory
endurance activities, muscular strength and endurance activities, body composition assessments, nutrition
assessment, nutrition analysis, and/or nutrition consultation provided by the lifetime wellness &fitness
program at auburn university. I, , the undersigned:

1) Hereby releases, waives, discharges and covenants not to sue auburn university, its board
oftrustees, officers, employees, agents, promoters, other participants, operators, trainers,
sponsors and advertisers involved in said fitness assessment, fitness program, and/or personal
training sessions, all for the purposes herein referred to as “releasee”, from all liability to the
undersigned, his personal representatives, assigns, heirs and next of kin for any and all loss or
damage, and any claim or demands therefor on account of injury to the person or property or
resulting in death of the undersigned, whether caused by the negligence of the releasee or
otherwise while the undersigned is participating in any or all of the aforementioned activities.

2) Hereby agrees to indemnify and save and hold harmless the release and each of them from any
loss, liability, damage, or cost they may incur due to the presence of the undersigned in or upon
any area or in any way participating in the aforementioned activities whether caused by the
releasee or otherwise.

3) Hereby assumes full responsibility for and risk of bodily injury, death or property damage due
to the negligence of releasee or otherwise while in or upon the facilities of auburn university and
while participating in any aforementioned activity.

4) I understand that i must have individual health insurance equal to or greater than the insurance
offered by the auburn university student government association, to participate in auburn university
health/wellness/fitness programs.

5) I expressly acknowledge and agree that the activities could be dangerous and involve risk of
serious injury and/or death. I further expressly agree that the foregoing release, waiver, and
indemnity agreement is intended to be as broad and inclusive as is permitted by law of the
province or state in which the event is conducted and that if any portion thereof is held invalid,
it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The
undersigned has read and voluntarily signs the release and waiver of liability and indemnity
agreement, and further agrees that no oral representations, statement or inducement apart
from the foregoing written agreement have been made. By signing this document, i hereby
acknowledge that i am at least 19 years of age and have read the above carefully before
signing, and agree with all of its provisions this

_________ Day of ____________________, 201____.

Participant signature Parent/Guardian (if participant is under 19 years of age)

Signature of witness (fitness staff)

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