70 Kunyung Road Mt Eliza VIC 3930

0417 363 9300416 238 500

Facebook: The Boiler RoomWeb: www.theBoilerRoom.net.au

Donna Day & Janet Kosovacwould like to extend a very warm welcome to you & offer you the

following health & wellbeing services:

Personal Training: highly personalised training for singles & pairs – general health & fitness, corporate wellness, weight management, strength, sports conditioning, older adult and pre/post natal wellness

Micro Group Training: all our micro group sessions have a maximum of 6 participants to promote an intimate & supportive environment. Sessions are conducted indoors & outdoors in our picturesque location by the bay that offers an abundance of training possibilities:

“Boost” Camp: A medium to high intensity early morning session designed to “boost” fitness, energy levels, endurance & well being Mon – Fri 6-7am

“S.P.I.C.E” Fitness Training: A “spicey” mix of modified Stretch, Power, Interval, Core & Endurance Mon – Fri 9-10am & 2-3pm

“Grey Power” Older Adults Wellbeing: A class specifically catering to the over 60’s & designed to improve cardiovascular fitness, muscle mass, strength, endurance & bone mass Mon – Fri 10-11am

‘Yummy Tummies” Pre/Post Natal Wellbeing: A customized program that incorporates safe, varied & enjoyable exercises, pelvic floor strengthening, Pilates/yoga elements, breath work, meditation & relaxation techniques Pre Natal: Tue & Thur 11am – 12pm Post Natal: Mon – Fri 11am-12pm

“Weigh 2 Go” Weight Management Program: safe & effective exercises, dietary guidance & weekly weigh ins for accountability Mon – Fri 12-1pm

Wellness Coaching: 12 week program “Be The Best You Can Be” optimise your potential, performance, relationships & life through our face to face/phone/Skype coaching service which can be tailored to suit your requirements, includes vision & goal setting, decisional balance & problem solving, wellness book & workbook.

Visit our website at http://www.theboilerroom.net.au/ or login to your Facebook account & search for “The Boiler Room” (look for our logo) for more info, pictures, timetable & private health insurance rebate information

We look forward to being able to assist you with your health & wellbeing goals. In order for us to do so we ask that you complete & return the following documentation prior to attending your first session or fitness appraisal – your right to privacy is our prime concern – the information obtained will be treated as confidential and will not be released to anyone without your consent:

1. Getting to Know You

2. PAR-Q & ACSM Initial Risk Stratification

3. Pre Fitness Test/Exercise Medical Warning

4. Medical Clearance

5. Notification of Indemnity

6. Fee Schedule/Terms & Conditions (Office Copy)

Welcome to The Boiler Room Wellbeing Centre

Name: ………………….............................. Age:…….. Height: ..........cm D.O.B………….Sex: M / F

Address:……………………………………………………………………………………………..Phone: (H)………………………..(B)……………………………..(M)…………………………..Email: ………………………………………………………………………………………………. (this email address will be used to forward all correspondence including fitness appraisal/weigh in data unless we are otherwise advised)

Emergency Contact: ………………………………………………Phone……………………….

Name of regular doctor: ………………………………….... Phone:…………………………………

Do you engage in any regular exercise/sport? If yes please specify?

..........................................................................................................................................................

What are your fitness goals (Circle)

Body fat reduction Muscular definition Cardiovascular fitness Increased flexibility

Muscular strength Body building Well being/Self Esteem Social Stress Reduction

Other:.................................................................................................................................................

Do you have any exercise preferences?

…………………………………………………………………………………………………………………

Please list any exercise equipment you have in your own home (Private PT clients only)

………………………………………………………………………………………………………………..

What is your short term fitness goal (6-8 weeks) …………………………………………………………………………………………………………………

What is your long term fitness goal (12 months) ………………………………………………………………………………………………………………..

Please circle which type of training you are interested in attending:

Personal Training: Single Pairs

Micro Group Exercise: Boost Camp S.P.I.C.E. Grey Power

Yummy Tummies Weigh 2 Go

Corporate: Fitness Teambuilding

Wellness Coaching: Singles Couples (12 x 1 hour face to face or via Skype)

Groups Corporate (3.5 hr workshop, 5 x 1 hr workshop or

12 x 1 hour workshop )

Date Starting: ..............................................................

Session Day/s: Mon Tue Wed Thur Fri

Session Times: ......... am/pm ..........am/pm ........am/pm .........am/pm .........am/pm

How would you prefer to pay: Casual 10 pack Monthly

Do you agree to photos of yourself being used for promotional purposes YES NO

1. Getting to Know You

Low risk = (men<45 women<55) & no more than 1 risk factor – can do maximal test/vigorous exercise without medical clearance

Mod risk = (men>45 women>55) or any age + 2 or more risk factors – Moderate test/exercise only (medical clearance for vigorous)

High risk = 1 or more Symptoms or Other - no testing/exercise without medical clearance – please use enclosed form

Name:………………………………….. Signature: ………………………….. Date:. ……………..

N.B. Please advise your trainer if any of the above information changes

2. PAR-Q & ACSM INITIAL RISK STRATIFICATIONPlease allocate 1 point to each yes answer

Questions Score

Risk Factors

Are you male and 45 or older or are you female and 55 or older?

Do you have a family history of heart disease, heart attack, bypass surgery, angioplasty, stroke, or sudden death prior to the age of 55 (male) or 65 (female)?

Have you smoked cigarettes in the past 6 months?

Is your usual blood pressure >=140/90 or do you take BP medication?

Is your LDL (bad) cholesterol > 130 (3.4mmol-L-1) or is your HDL (good) cholesterol < 40 for men or 50 for women (1.3mmol-L -1) or is your total cholesterol >= 200 (5.5mmol-L-1) or are you on lipid lowering medication or you do not know what your levels are?

Is your fasting glucose >=6.1mmol/L or you do not know what your fasting glucose is?

Is your weight/height2 (BMI) >=30? or is your waist girth measurement >100cm?

Are you taking any other medication and if so what is it for? ..............................................................................................................

Do you have any hormonal imbalances & if so please describe? .......................................................................................................

Do you get less than 30 mins of moderate physical activity most days of the week?

TOTAL RISK FACTOR SCORE

Symptoms

Do you ever have pain/discomfort in your chest or surrounding areas?

Do you ever feel faint/dizzy other than when sitting up rapidly or lose consciousness?

Do you ever find it difficult to breathe when you are lying down or sleeping?

Do your ankles become swollen (other than after a long period of standing)?

Do you ever have heart palpitations, or unusual periods of rapid heart rate?

Do you ever experience pain in your legs – intermittent claudication?

Has a physician ever said you have a heart murmur/condition and/or that you should only do exercise prescribed by a doctor?

Do you feel unusually fatigued/breathless with usual activities?

TOTAL SYMPTOMS SCORE

Other

Do you have any of the following diseases: heart condition/disease, chronic obstructive pulmonary disease (emphysema or chronic bronchitis), asthma, interstitial lung disease, cystic fibrosis, diabetes, thyroid disorder, renal disease or liver disease or any other cardio, pulmonary or metabolic disease &/or are you on medication for any of the above conditions?

Do you have any bone/joint problems, such as arthritis or a past injury that might get worse with exercise? If so please describe

Do you have a heavy cold or flu, or any other infection/infectious disease?

Are you pregnant or have you given birth within the past 8 weeks?

Do you have any other problem that might make it difficult/unsafe for you to exercise? If so please describe

TOTAL OTHER SCORE

If you have any of the abovementioned conditions please circle them (or another medical condition not listed) and obtain medical clearance from your doctor prior to any fitness test or exercise program commencing.

Avoid eating, drinking, stress, caffeine, alcohol &/or exercise 2 hours prior to any fitness test

Fitness tests will be stopped if the following signs & symptoms appear: abnormal ECG changes, blood pressure &/or heart rate responses or equipment malfunction

Be sure to advise your PT if you experience nausea, dizziness, lack of breath &/or pain during a fitness test or during exercise.

This form & the PAR-Q form are not intended to put you off beginning your health & fitness program but are used to gather important information which will be used to develop an appropriate fitness appraisal format and/or exercise program/session making sure that the tests/programs are relevant and that any injuries and your medical history, goals & preferences are taken into account. If you have any difficulties completing these forms please do not hesitate to ask for our assistance.

Name: .................................................. Signature: .............................................. Date: ..............

3. Pre Fitness Test/Exercise Medical Warning

RELATIVE CONTRAINDICATIONS ABSOLUTE CONTRAINDICATIONS

Left main coronary stenosis (narrowing of coronary artery)

Moderate stenotic valvular heart disease (narrowing of mitral valve)

Electrolyte abnormalities such as hypokalemia (decreased serum potassium levels) or hypomagnesemia (decreased serum magnesium levels)

Severe arterial hypertension (resting BP 200/110)

Tachyarrhythmia (rapid, irregular heartbeat) or bradyarrhythmia (slow, irregular heartbeat)

Hypertrophic cardiomyopathy or other forms of outflow obstruction

Ventricular aneurysm (sac like protrusion from heart)

Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated by exercise

Uncontrolled metabolic diseases such as diabetes, thyrotoxicosis (excessive thyroid hormone) or myxedema (hypothyroidism characterised by relatively hard oedema of subcutaneous tissue)

Chronic infectious diseases such as mononucleosis, hepatitis or AIDS

Recent significant change in resting ECG suggesting significant ischemia (restricted blood flow to the heart), recent (within 2 days) myocardial infarction (death of heart tissue caused by insufficient blood supply), or other acute cardiac events

High risk unstable angina (chest pain)

Uncontrolled cardiac/ventricular/atrial arrhythmia (irregular heartbeat) causing symptoms or compromised cardiac function

Acute congestive heart failure

High/third degree atrio/ventricular (AV) heat block (slow heart rate & fainting)

Severe symptomatic aortic stenosis (narrowing of aortic valve opening)

Uncontrolled symptomatic heart failure (right ventricular failure, decreased venous flow to lungs)

Acute system/pulmonary embolus (occluded vessel caused by a detached clot, mass of bacteria or foreign body)

Acute/active/suspected myocarditis (inflammation of heart tissue) or pericarditis (inflammation of the membrane surrounding the heart and major blood vessels)

Suspected or known dissecting aneurysm (splitting of an arterial wall by blood entering through a tear, commonly in the aorta, near the aortic valve)

Intra cardiac thrombi/thrombophlebitis

Acute infections or significant emotional stress/psychosis

To Whom it May Concern,

Re: Client Name: …………………………………………….

This client has been sent to you to gain a medical clearance to participate in a fitness test/program.

Medical Clearance:

Please select one of the following options:

This client is able to participate in any fitness related activity/program at your facility

This client may participate in fitness activities at your facility based on the following guidelines:

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………..

Patient’s last blood pressure reading: …………./…………….

Patient’s last cholesterol reading: ………………………….

Please indicate by your signature below that your patient is medically cleared to participate in fitness tests/training.

…………………………………. ….………………………….. ………………….Print name of physician Signature of physician Date

Physician’s phone: (…..) ………………………….

Please contact either Donna Day on 0417 363 930 or Janet Kosovac on 0416238500 if you have any concerns in relation to your patient’s participation in the program.

4. MEDICAL CLEARANCE

5. NOTIFICATION OF INDEMNITYPlease read and sign the following:

I ………………………………………......….. of ……………………………………………………………..........................

understand and accept that:

• there exists the possibility that certain abnormal changes and risks may occur during training or testing sessions

• I am responsible for monitoring my own condition throughout the tests and training sessions, and should any unusual symptoms occur, I will cease my participation and inform the trainer of the symptoms. Efforts will be made to minimize these occurrences by preliminary screening and/or precautions & observations during the testing or training.

• the possibility may and does exist that accidental or unavoidable discomfort or injury may occur

• I should obtain a medical clearance before undertaking fitness testing and/or training if:

I. I have or have had any medical condition and/or;

II. I am above the age of 45 (male) or 55 (female) and/or;

III. the PAR Q – ACSM Initial Risk Stratification score indicates that I am classified as high risk and I wish to take part in submaximal (moderate) fitness testing/training or;

IV. the PAR Q – ACSM Initial Risk Stratification score indicates that I am classified as moderate risk and I wish to exercise at a vigorous level (higher than moderate);

• in the event that a medical clearance is required, it is my responsibility to ensure this clearance is obtained and that failure to do so is at my own risk.

• that without a medical clearance, Namaste PT and/or Inspirational Fitness may decide no further training of myself can take place until such medical clearance is obtained.

• this clearance will be treated as privileged and confidential, as will all other personal details and that these will not be released or revealed without my express written consent.

• in the event of injury or illness, whilst in attendance at a Namaste PT and/or Inspirational Fitness appraisal &/or training session, I give my permission for a representative of Namaste PT and/or Inspirational Fitness to make decisions on my behalf concerning the most appropriate action to be taken with respect to my condition.

•as part of their commitment to maintaining a high level of Occupational Health & Safety Management, the Melbourne Business School requires me to sign this form indemnifying the School from responsibility or liability associated with the use of The Boiler Room gymnasium facilities and/or School grounds. And that furthermore the management of the School reserves the right, at its absolute discretion, to suspend any activity deemed to jeopardise the health or safety of any person or persons. If the School management believes that this activity could affect the smooth running of the School’s business, its reputation, security or safety, it reserves the right to intervene and/or suspend the activity.

•as a client of Namaste PT and/or Inspirational Fitness, that individual acts can and do affect the whole School community and that the School will not tolerate behaviour that impedes fellow clients of the School or exposes them to discrimination or harassment, and that the School will maintain its duty of care at all times and will take all reasonable and practicable steps to ensure the safety of clients and staff from accident or injury.

In signing this form, I affirm that I have read it in its entirety and that all my questions regarding the testing and proposed exercise regime have been answered to my satisfaction. My participation is totally voluntary, I know that I can discontinue my participation at any time without penalty. I agree to assume the risk of such testing and exercise, and further agree to hold harmless Namaste PT and/or Inspirational Fitness and/or Melbourne Business School and their subsidiaries, affiliates, employees, agents and any other persons associated from any and all claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims that may result from my injury or death, accidental or otherwise arising in any way from the testing or exercise regime.

Participant Signature: ……………………………………………… Date ………………………

Witness Signature: ……………………………………. ………….. Date …………………………

6. BOILER ROOM FEE SCHEDULE – OFFICE COPYas of 1/7/11

Service Casual 10 pack 12 pack Workshop 1 p/w

2 p/w

3 p/w

4 p/w

5 p/w

Personal Training

Singles 70 600 - - - - - - -

Pairs 60 500 - - - - - - -

Micro Group Exercise 20 - - - 60 120 180 240 300

Grey Power Only 20 - - - 40 80 120 160 200

Wellness Coaching

Singles & Couples - - 600

Group & Corporate (min 4 and max 20):

3.5 hour workshop - - - 200 - - - - -

Paid monthly

TERMS & CONDITIONS1. All fees shown are $ per person2. Micro Group Exercise fees (other than casual) are per person per month and must be paid at the beginning of

each month to secure your place3. Clients paying on a casual basis must pre-book prior to attending to secure their place in the session.4. Personal Training clients receive a training journal, calorie counting book, tailored program, regular fitness

appraisals & SMS reminder service.5. The Weigh 2 Go weight management program requires a training journal & calorie counting book which can be

purchased through us for $35 and a heart rate monitor which can be purchased online.6. Namaste PT & Inspirational Fitness reserve the right to close on weekends, public holidays, during part of the

school holidays and/or due to Melbourne Business School closures – in the latter instance alternative venues will be organised or appropriate fee adjustments/package deferrals will be provided by Namaste PT/Inspirational Fitness at their discretion

7. If requested, client services may be deferred for other reasons at the discretion of the trainer8. Cancellations made within 24 hours prior to training will not be refundable or transferable9. In the event a client is late, the session will conclude at the pre-set time so as not to inconvenience other clients10. No shows without notice are subject to a 3 strike policy – in this instance a training place will be held for 3 weeks

and then offered to other clientele.11. Melbourne Business School staff receive 50% discount on all training services12. Payments must be made prior to training and can be made via cash, cheque or direct deposit (preferred) to:

If you are training with Donna:If you are training with Janet:Account Name: Namaste PT Account Name: Inspirational FitnessBank: Commonwealth Bank Bank: Commonwealth BankAccount No: 10253055 Account No: 10132809Branch: Mt Eliza Branch: DromanaBSB: 063 550 BSB: 063 822

Please use your name & session type as the online banking reference

I have read the enclosed information and I understand & agree to the fees, terms & conditions set down by Namaste PT & Inspirational Fitness

Signed by client: ……………………………………. Date: ………………………………..

Combine wellness coaching with a PT 10 pack & save $200 p.p. per package

PLEASE CIRCLE YOUR PREFERRED OPTION

BOILER ROOM FEE SCHEDULE – CLIENT COPYas of 1/7/11

Service Casual 10 pack 12 pack Workshop 1 p/w

2 p/w

3 p/w

4 p/w

5 p/w

Personal Training

Singles 70 600 - - - - - - -

Pairs 60 500 - - - - - - -

Micro Group Exercise 20 - - - 60 120 180 240 300

Grey Power Only 20 - - - 40 80 120 160 200

Wellness Coaching

Singles & Couples - - 600 -

Group & Corporate (min 4 & max 20):

3.5 hour workshop - - - 200 - - - - -

Paid monthly

TERMS & CONDITIONS1. All fees shown are $ per person2. Micro Group Exercise fees (other than casual) are per person per month and must be paid at the beginning of

each month to secure your place3. Clients paying on a casual basis must pre-book prior to attending to secure their place in the session.4. Personal Training clients receive a training journal, calorie counting book, tailored program, regular fitness

appraisals & SMS reminder service.5. The Weigh 2 Go weight management program requires a training journal & calorie counting book which can be

purchased through us for $35 and a heart rate monitor which can be purchased online.6. Namaste PT & Inspirational Fitness reserve the right to close on weekends, public holidays, during part of the

school holidays and/or due to Melbourne Business School closures – in the latter instance alternative venues will be organised or appropriate fee adjustments/package deferrals will be provided by Namaste PT/Inspirational Fitness at their discretion

7. If requested, client services may be deferred for other reasons at the discretion of the trainer8. Cancellations made within 24 hours prior to training will not be refundable or transferable9. In the event a client is late, the session will conclude at the pre-set time so as not to inconvenience other clients10. No shows without notice are subject to a 3 strike policy – in this instance a training place will be held for 3 weeks

and then offered to other clientele.11. Melbourne Business School staff receive 50% discount on all training services12. Payments must be made prior to training and can be made via cash, cheque or direct deposit (preferred) to:

If you are training with Donna:If you are training with Janet:Account Name: Namaste PT Account Name: Inspirational FitnessBank: Commonwealth Bank Bank: Commonwealth BankAccount No: 10253055 Account No: 10132809Branch: Mt Eliza Branch: DromanaBSB: 063 550 BSB: 063 822

Please use your name & session type as the online banking reference

Combine wellness coaching with a PT 10 pack & save $200 p.p. per package