Personalized Recreation Instruction

UCLA RECREATION: Personal Fitness Training - Request Form

Please fill out this form to request private fitness instruction.

The PFT Manager will contact you within 3-5 business days to confirm receipt of request and provide further details.

Private Instruction and Lessons include

Personal Fitness Training
- Private 1:1
- Semi private 2:1
- Small group 3-4:1
- Discounted bundled packages

Elite Private Instruction and Lessons include

Alexander Technique (Private 1:1)
Nutrition (Private 1:1)
Pilates(Private 1:1)
Yoga (Private 1:1)

Request Type*

New Request for Instruction Renewal Request for Additional Instruction

Requesting this service for *

Myself My dependent

Submit one application per participant. Semi-Private and Group participants must submit individual applications. Individuals over 18+ years must request service for themselves

UCLA Campus Affiliation*

Current UCLA Undergrad Student Current UCLA Grad Student Current UCLA Staff/Faculty UCLA Emeriti/Retiree UCLA Alumni Community

Requesting an individual service for:*

FITWELL: Personal Fitness Training, Yoga, Pilates, Alexander Technique Nutrition - Virtual Only

Requested Instructor Ratio (if available)*

Private / Individual - 1 participant Semi Private - 2 participants Small Group - 3-4 participants

Individual requests must be submitted for Semi-Private and Small Group instruction

Name(s) of group participant(s)

Recreation Policies & Pricing

Pricing & Rates - Personal Fitness Training & Nutrition

Semi-Private Instruction

Hourly Rate/person. 2 participants maximum. Both participants must submit the application form, participation waiver and payment individually. If only one person attends, a private 1:1 session is required.

Small Group Instruction

Hourly Rate/person. 4 participants maximum. All participants must submit the application form, participation waiver and payment individually. If only one person attends, a private 1:1 session is required.

Online Purchase REQUIRED

You must purchase your private lesson session(s) online at least 24 hours prior to your first in person and/or virtual appointment. Purchased sessions do not change waitlist position.

Recreation Policy

Cancellations: You must provide the instructor with 24-hours’ notice when canceling or rescheduling a session in order to not be charged for that session. You must receive a confirmation call from the instructor.
Refunds: All requests must be submitted and timestamped no later one year of purchase using the Cancellation & Refund Request form. All private instruction expires one year from the date of purchase. Any unused sessions that have not expired are eligible for a refund (minus a $25 processing fee). The value for expired sessions can be applied towards a new Recreation purchase; no refunds will be offered for any unused, expired sessions.
Additional policies outlined on our Member Services Page

I have reviewed and agree to all UCLA Recreation policies.*

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Participant Information

Participant Name*

First Name

Last Name

University ID Number*

Student ID, Employee ID or Recreation Card ID

Email Address*

Phone Number*

Please provide a USA phone number, as we are unable to contact international phone numbers

Preferred Method of Communication*

Phone Call Email Text Message

Parent/Guardian Name of Participant*

First Name

Last Name

Participant Availability - Personalized Fitness, Yoga, Pilates, Alexander Technique

Please indicate specific time frames that you are most available for personalized instruction:*

Please indicate specific time frames that you are most available for personalized instruction:
	Morning (6am-12pm)	Afternoon (12pm-5pm)	Evening (5pm-8pm)	Not Available
Monday	Please indicate specific time frames that you are most available for personalized instruction:: Monday (Morning (6am-12pm))	Monday (Afternoon (12pm-5pm))	Monday (Evening (5pm-8pm))	Monday (Not Available)
Tuesday	Tuesday (Morning (6am-12pm))	Tuesday (Afternoon (12pm-5pm))	Tuesday (Evening (5pm-8pm))	Tuesday (Not Available)
Wednesday	Wednesday (Morning (6am-12pm))	Wednesday (Afternoon (12pm-5pm))	Wednesday (Evening (5pm-8pm))	Wednesday (Not Available)
Thursday	Thursday (Morning (6am-12pm))	Thursday (Afternoon (12pm-5pm))	Thursday (Evening (5pm-8pm))	Thursday (Not Available)
Friday	Friday (Morning (6am-12pm))	Friday (Afternoon (12pm-5pm))	Friday (Evening (5pm-8pm))	Friday (Not Available)
Saturday	Saturday (Morning (6am-12pm))	Saturday (Afternoon (12pm-5pm))	Saturday (Evening (5pm-8pm))	Saturday (Not Available)
Sunday	Sunday (Morning (6am-12pm))	Sunday (Afternoon (12pm-5pm))	Sunday (Evening (5pm-8pm))	Sunday (Not Available)

Please identify any specific time and days of the week that you would like to schedule your personal instruction

All scheduling is dependent on the availability of facility space and instructors. Generally between working hours of 6AM-9PM Monday-Saturday

Personalized Fitness, Yoga, Pilates, Alexander Technique

Our qualified, nationally certified personal trainers will provide you with the right information and the right training to help you achieve your goals.

Contact:

Liz Au

(213) 655-6381

lau@recreation.ucla.edu

Fitwell Service Requested*

Personal Fitness Training Private Pilates Private Yoga Alexander Technique

Preferred Location of Training*

JWC: 2131 John Wooden Center KREC: 11100 Kinross Avenue BFIT: 251 Charles E Young Drive West BFIT Virtual No preference

KREC is available for Faculty/staff and graduate students.

Please share any additional information that might be helpful in selecting a personal fitness trainer or instructor to meet your needs. (You may request a specific trainer here.)

Participant Availability - Virtual Nutrition

Please indicate specific time frames that you are most available for personalized instruction:*

Please indicate specific time frames that you are most available for personalized instruction:
	Morning (6am-12pm)	Afternoon (12pm-5pm)	Evening (5pm-8pm)	Not Available
Monday	Please indicate specific time frames that you are most available for personalized instruction:: Monday (Morning (6am-12pm))	Monday (Afternoon (12pm-5pm))	Monday (Evening (5pm-8pm))	Monday (Not Available)
Tuesday	Tuesday (Morning (6am-12pm))	Tuesday (Afternoon (12pm-5pm))	Tuesday (Evening (5pm-8pm))	Tuesday (Not Available)
Wednesday	Wednesday (Morning (6am-12pm))	Wednesday (Afternoon (12pm-5pm))	Wednesday (Evening (5pm-8pm))	Wednesday (Not Available)
Thursday	Thursday (Morning (6am-12pm))	Thursday (Afternoon (12pm-5pm))	Thursday (Evening (5pm-8pm))	Thursday (Not Available)
Friday	Friday (Morning (6am-12pm))	Friday (Afternoon (12pm-5pm))	Friday (Evening (5pm-8pm))	Friday (Not Available)
Saturday	Saturday (Morning (6am-12pm))	Saturday (Afternoon (12pm-5pm))	Saturday (Evening (5pm-8pm))	Saturday (Not Available)
Sunday	Sunday (Morning (6am-12pm))	Sunday (Afternoon (12pm-5pm))	Sunday (Evening (5pm-8pm))	Sunday (Not Available)

Please identify any specific time and days of the week that you would like to schedule your personal instruction

All scheduling is dependent on the availability of facility space and instructors. Generally between working hours of 6AM-9PM Monday-Saturday

Private Nutrition - Virtual

Please list all of your nutrition goals.

What (if any) eating habits would you like to change?

Please list any food allergies, food intolerances or special diet(s) here.

Please share any additional information that might be helpful in selecting a Registered Dietitian to meet your needs. (You may request a specific RD here)

Participant Goals & Background

Please detail the participant's fitness and training goals*

Have the participant performed planned, structured physical activity for at least 30 minutes at moderate intensity on at least 3 days per week for the last 3 months?*

Yes No

Briefly describe the participant's current fitness routine*

What is your occupation/work type? If participant is a minor, please write N/A

Please list all prescription and non-prescription medications the participant is currently taking. If none, type N/A*

Please list any injuries the participant has. If none, type N/A*

Do you have any special requirements/considerations for this private instruction? Please describe below

Pre-Participation Heath History Screening

CARDIOVASCULAR HISTORY: Please check any signs and symptoms that you experience:*

Chest discomfort with exertion Unreasonable breathlessness Dizziness, fainting, blackouts Ankle swelling Unpleasant awareness of a forceful, rapid or irregular heart rate Burning or cramping sensations in your lower legs when walking short distances None of the above

Other:

If you indicated "none", medical clearance is not necessary.

If you indicated that you have any of these health statements under Cardiovascular History: Signs & Symptoms OR Medical Conditions, seek medical clearance before engaging in or resuming exercise. Please have your physician submit the physician’s release form. We will not confirm your request until this is received: Physician's Release Form

I acknowledge that the above statements are accurate and I have read through the Pre-participation Screening.*

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Manager Confirmation

Manager Name*

First Name

Last Name

Manager Email*

Checkbox

Confirms with customer directly Confirms availability / Schedules instructor Sends purchase link to customer directly Confirms payment prior to first session Committed to managing Multi-visit pass usage in Fusion

Manager Responsibilities

Notes