Author: Melissa Gage

CLIFTON SPRINGS FAMILY YMCA

PERSONAL TRAINING REGISTRATION FORM

Appointments are set up on an individual basis.
Payment is required before first training session.

PLEASE PRINT. THANK YOU
Name: ____________________________________________________ DOB: ____/____/____
Address: __________________________________________________________
City: ______________________________ Zip: __________________
Phone: ___________________ Email: _____________________________

TRAINING OPTIONS :
c Personal Training c Teen Personal Training
c 2-1 hour sessions $80 c 2-1 hour sessions $60
c 5-1 hour sessions $180 c 5-1 hour sessions $129
c 10-1 hour sessions $300 c 10-1 hour sessions $215
REASON(S) FOR TRAINING:
c Weight Loss c Sports Conditioning c Rehab from Injury c Gain Strength
c Improve Technique c Life Style Change c Increase Endurance c Build Power
c Other please explain ________________________________________________________________________________________________________________
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TRAINING PREFERENCE:
c Weekdays c Weekends
c Mornings c Afternoons c Evenings
I understand that there is a risk of injury associated with participation in any YMCA program or use of its facilities. In consideration for Clifton Springs Family YMCA participation in it’s programs an /or use of it’s facilities, I assume full responsibility for any and all injuries, damages or losses in any way arising from or connected with participation.
Signature ______________________________________________________________
Parent’s signature (if under 18 yrs old) ______________________________________
Please submit to Member Service with payment and you will be contacted by a trainer to set up an appointment.
Wellness Center Office Use Only
Date RECEIVED: ____/____/____ Date Contacted: ____/____/____
Instructor’s note:
______________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________

Clifton Springs Family YMCA § 5 Crane Street § Clifton Springs, New York 14432 § 315.462.6184 § www.csaymca.org