On Saturday, May 10 all Oak Brook Park District Facilities will open at 10am. This late opening is due to the annual Pink 5k event.

Oaks Amphitheater Rental Request Form

Client Information

First name

Last name

Preferred Phone

Confirm email

Date

*Parental consent is required for minors.

Available (Please list all available times)

How many times per week do you want to work with your personal trainer?

Please Provide your availability for each day.

Time	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
AM	*	*	*	*	*	*	*
PM	*	*	*	*	*	*	*

If you have preferred times and days for personal training, please provide:

Activities & Goals

List your three main fitness/wellness goals:

What are your goals for personal training (Weight loss, strength, cardiovascular fitness, etc)?

How do you see the personal trainer helping you to meet your goal?

What types of physical activity interest you? Check all that apply.

Activity	Participates Currently	Would like to
Circuit Training	*	*
Strength Training	*	*
High Intensity Interval	*	*
Power Lifting	*	*
Competitive Sports	*	*
Group Fitness	*	*
Tennis	*	*
Pickleball	*	*
Stretching/ Flexibility	*	*
Swimming	*	*
Walking	*	*
Running	*	*

Please list your current physical activity/exercise:

How many times per week do you currently exercise?

How long do you spend exercising per session?

If your participation is lower than you would like it to be, what are the reason?

Have you ever had personal training before? Please explain:

Health History

Physician's Name

Physician's Phone

Medical Group/Hospital Affiliation

Physician's Fax

Depending on your health history, we may contact your physician to receive their consent for you to participate in personal training.

Are you participating in any other exercise program?

YES

If yes, please describe your exercise program

Emergency Contact

Health history

Do you now, or have had in the last:	NO/YES	Please explain if "YES"
History of heart problems, chest pain or stroke?	NO YES
Increased blood pressure?	NO YES
Difficulty with physical exercise?	NO YES
Advice from physical not to exercise?	NO YES
Any chronic illness or condition?	NO YES
Recent surgery in the last 12 months?	NO YES
Pregnancy (now or within the last months)?	NO YES
History of breathing or lung problems?	NO YES
Muscle, joint or back disorder, or any previous injury still affecting you?	NO YES
Diabetes or thyroid condition?	NO YES
Cigarette smoking habit?	NO YES
Obesity (more than 29% over ideal body weight)?	NO YES
Increased blood cholesterol?	NO YES
History of heart problems in immediate family?	NO YES
Hernia or any condition that may be aggravated by lifting weights?	NO YES
Any recent hospitalization?	NO YES
Are you taking any prescription or nonprescription medications?	NO YES

You will receive a phone call from a certified fitness trainer within 1-2 business days of this inquiry. Please allow an additional day if submitting form during the weekend. If you have any further questions, please contact Valerie Louthan, Superintendent of Facilities, at (630) 645-9534 or vlouthan@obparks.org

Oaks Amphitheater Rental Request Form

Client Information

Available (Please list all available times)

Activities & Goals

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