First Name *

Last Name *

Confirm Email *

Please carefully read and select any of the following medical statements that may apply to you. If none apply, please confirm this with the bottom selection. *
My doctor has said that I have a heart condition and that I should only do physical activity recommended by a doctor.
I feel pain in my chest when I do physical activity
In the past month, I have had chest pain when not doing physical activity.
I lose my balance because of dizziness and have lost consciousness when doing physical activity.
I have a bone or joint problem (for example; back, knee, or hip) that could be made worse by a change in physical activity.
I am currently taking prescription drugs for blood pressure and/or a heart condition.
Other reason that is not listed above.
I confirm that none of the statements above apply.

If you selected "Other reason", please briefly describe below: *

Record Request

In order to comply with all patient confidentiality guidelines, we are requesting that you complete this release form, which will allow us to communicate with your physician, therapist, coach or other provider, if we have any concerns related to your medical history. If you do not currently have a physician, please list your most recent physician’s information and date of last visit.

Please download and fill out this Health Care Provider (HCP) Record Request form with your HCP prior to your intake appointment: HCP Record Request

Please note that you only need to complete the highlighted sections from the first three pages. The bottom of the third page is to be completed after the form is returned to you by your Health Care Provider. You can fax the completed form to our office at (616) 331-3960.

*You will not be able to receive your personalized training program until the Record Request has been completed and faxed back to our office. If you have any questions, please feel free to contact our office via email, [email protected], or phone at (616) 331-3659. Our office is open Monday - Friday 12:00 p.m. - 5:00 p.m.

UFit and Personal Training Program

Acknowledgment of Risk, and Release of Liability

Purpose:  The purpose of your UFit and/or Personal Training program is to assist you in establishing/increasing/maintaining positive exercise behaviors as well as improving health-related physical fitness.  Your individual exercise program will be designed based on your interests, current self-reported fitness level, and the exercise equipment you have available.

Acknowledgment of Risk and Release of Liability: I hereby declare, assert, and affirm that my participation in the Grand Valley State University Recreation and Wellness UFit and/or Personal Training program, is done having voluntarily and knowingly assumed all risks involved in this event. The immediate physical risk(s) associated are those correlated with normal, vigorous physical activity. These risks include, but are not limited to, bodily discomfort and fatigue, muscular soreness, pulled or strained muscles, overuse injuries/soft tissue damage, bodily injury resulting from falls, and the rare instance of abnormal changes/responses of the cardiopulmonary system to exercise. Adverse responses include abnormal blood pressure, heart arrhythmias, and the very rare instance of heart attack, stroke, or sudden death.  Before starting any fitness program, you should consult your physician or other health care professional to determine if it is right for your needs.

In consideration of acceptance of this contract allowing my participation in the above stated program and intending to be legally bound thereby, I hereby for myself, my heirs, executors, administrators, and assigns, WAIVE AND RELEASE any and all rights and claims for negligence, injuries, damages, equipment, facilities, staff training, or losses that I may incur involved in the above stated Recreation & Wellness program, specifically Grand Valley State University, its respective employees, agents, representatives, successors, and assigns for any and all activities connected with the above stated program. If I am a Grand Valley employee (faculty or staff member), I also understand that I do hereby WAIVE any and all rights or benefits under the State of Michigan Worker’s Compensation laws for any injury incurred as a result of my participation in this event.

Research & Data Use: I hereby authorize Recreation and Wellness, Grand Valley State University and their respective agents to release information obtained during this activity for the purpose(s) of programmatic and research needs as well as for aggregate data supplemental research, articles and presentations.

Acknowledgement of Understanding *
I have read, understand, and agree to the above statements.

Please sign below: