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General Information

Date
Date
First Name*
Last Name*
Date of Birth
Date of Birth
Age
Address
City
Province
Postal Code
Home Phone*
Cell Phone
Email
Occupation
Emergency Contact Information*
Please provide a name, phone number and relationship with you.
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Are you satisfied with your current level of fitness?
1. Yes
2. No
How often do you participate in physical activity per week?
1. 5 to 7 times
2. 3 or 4 times
3. 1 or 2 times
4. Not at all
If you are active, please list your exercises:
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Please list, in priority, the fitness goals you would like to achieve in the next 12 weeks:
Please list, in priority, the fitness goals you would like to achieve in the next 6 to 12 months:
What is preventing you from attaining your goals right now?
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If you've decided, please indicate which personal training package you are interested in purchasing. What package are you interested in?
Please note that there is a 24-hour cancellation policy on all personal training appointments and a 2-year expiry on all personal training memberships.
For more information about these packages, including prices, please visit our Personal Training page.
Personal Training page
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By checking "I consent" you are consenting to the voluntarily collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act. The information provided by you will be used solely for the purpose of providing you with personal training services.Your information will not be used for any other purpose. If you have any questions about the collection, correction and/or use of your personal information please contact the Health & Fitness Program Coordinator, City of Coquitlam, Parks, Recreation and Culture at 604-927-6004.*
1. I consent

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