First Name *

Last Name *

GVSU Email Address *

Preferred Phone Number *

Preferred Method of Contact for Appointments *
- Select Option Zoom Facetime Telephone Email

Has your doctor ever said that you have heart condition and that you should only do physical activity recommended by a doctor? *
- Select Option Yes No

Do you feel pain in your chest when you do physical activity? *
- Select Option Yes No

In the past month, have you had chest pain when you were not doing physical activity? *
- Select Option Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness? *
- Select Option Yes No

Do you have a bone or joint problem (for example, back, knee or hip) thatcould be made worse by a change in your physical activity? *
- Select Option Yes No

Are you currently taking prescription drugs for blood pressure or heart condition? *
- Select Option Yes No

Do you know of any other reason why you should not do physical activity? *
- Select Option Yes No

If you selected yes, please briefly describe below: *

What goal(s) do you hope to achieve with this program? *

Why are your goals important to you? *

Is there a specific date you would like to reach your goals by? *

Fitness Experience Level *
- Select Option Very little experience Some experience Lots of experience

How many days per week are you currently participating in physical activity? *

How many days per week will you be able to commit to your UFit fitness plan? *

Please select which day(s) of the week you prefer NOT/are NOT able to workout: *
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Are there any exercises you cannot or do not like to perform? Please explain. *

What fitness equipment do you have available to use? Please be as specific as possible *

UFit Program

Acknowledgment of Risk, and Release of Liability

Purpose:  The purpose of your UFit 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 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.