Fit Orientation 08

FITNESS ORIENTATION Registration Form For your ease of use, please complete this form on a computer. Then email it to [email protected] to schedule your Fitness Orientation. Personal Information Please type or print neatly, so we meet your needs accurately.

Name PID Number Phone Number Email Address University Status Gender Orientation Leader Gender Facility Preference How did you hear about this service?

1st YR SO JR SR GRAD FAC/STAFF Male Female Male Female No Preference Rams Head Rec. Center Student Rec. Center Email Online SRC/RHRC Word of Mouth DTH Special Event Other

Fitness Goals Please use the drop-down menus to rank the accuracy of the five goals listed below. Most Important 1 2

3

Click - I want to improve my cardiovascular fitness Click - I want to reshape or tone my body Click - I want to increase my strength

4

Least Important 5

Click - I want to reduce my body-fat Click - I want to improve my flexibility Additional Goals:

Equipment Preferences Please indicate the type[s] of equipment you are interested in learning about: Exercise Bike Elliptical Trainer Concept II Rower Treadmill Stair Climber/Stepmill Strength Equipment Other [please specify]:

Please email the completed registration form to Jordan Albertson, [email protected], in order to schedule an appointment.

Revised on 8.15.2008

University of North Carolina at Chapel Hill – Department of Exercise and Sport Science

AGREEMENT AND RELEASE OF LIABILITY In consideration of being allowed to participate in the activities and programs of the University of North Carolina at Chapel Hill Department of Exercise and Sport Science and in consideration of the voluntary nature of such participation and use, I hereby release, hold harmless, and forever discharge The University of North Carolina at Chapel Hill, its employees and agents, from any and all liability, claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss, property damage, or personal injury, including death, that may be sustained by me or to any property belonging to me, while participating in such activity. I, the undersigned, hereby give permission for the staff of the University to seek emergency medical attention to be given for me to receive medical attention in the event of accident, injury or illness. I will be responsible for any and all costs of such medical attention and treatment. I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment, are potentially hazardous activities. I also understand that fitness and recreational activities involve a risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment or machinery except as hereinafter stated. I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in my activities. I am fully aware of the risks and hazards associated with participation in physical activity. I hereby elect voluntarily to participate in said activity and fully acknowledge that the activity may be hazardous to me and my property. I agree to comply fully with the rules/regulations and directions provided by the staff at any of the EXSS/Campus Recreation facilities. Further, I understand that I will be disqualified from the activity in the event that I fail to comply with said rules. This release and hold harmless agreement is binding on myself, my heirs, my assigns, and personal representatives. I, ___________________________________________, am 18 years of age or older. [Print] _____________________________________ _______________________________ Signature Date

Administrative Use Only: SRC RHRC With: _______________________ On: _____________ Information added to Participant Tracker Receptionist Initials: ______________________

At: ____________

Revised on 8.15.2008