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Personal Training

Training Interest Form

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Member Name: *

First Name:

Last Name:

Other Name

Date of Birth:

Month

Day

Year

Phone Number:

Email: *

Personal training interest (check all that apply):

Strength training

Aquatic training in pool

Balance / Core training

Weight management

Cardiovascular training

Flexibility training

Pilates Reformer training (Tyler location only)

Private swim lessons

Choose a Location: *

Time of Day:

Morning (6a.m. - 11a.m.)

Midday (11a.m. - 4p.m.)

Evening (4p.m. - 9p.m.)

Training session duration:

60 minutes

30 minutes

Days for training:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Please list any specific needs that should be considered when selecting the proper trainer. (high blood pressure, diabetes, cardiac therapy):

What are your main goals to accomplish through personal training?

Leave this field blank

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UT Health East Texas

1000 S. Beckham Ave. Tyler, TX 75701 903-596-DOCS