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Spring 2017 1-1 Wellness Coaching Registration

Spring 2017 1-1 Wellness Onsite Coaching Registration Form

Please read and complete the online registration form in order to register for onsite coaching with your Certified Health & Wellness Coach.

1. Type your Last Name: *This question is required.

2. Type your First Name: *This question is required.

3. Email: *This question is required.

4. Best phone number to reach you: *This question is required.

5. Semester *This question is required.

6. What campus are you primarily located at? *This question is required.

Bradenton
Venice
LWR
Other - Write In Please enter an 'other' value for this selection.

7. Pre-Program Survey

Space Cell	Daily	Often	Sometimes	Seldom	Never
I set an intention for the day	I set an intention for the day: Daily	I set an intention for the day: Often	I set an intention for the day: Sometimes	I set an intention for the day: Seldom	I set an intention for the day: Never
I have defined SMART (Specific, Measurable, Achievable, Realistic, Trackable) goals for the New Year	I have defined SMART (Specific, Measurable, Achievable, Realistic, Trackable) goals for the New Year: Daily	I have defined SMART (Specific, Measurable, Achievable, Realistic, Trackable) goals for the New Year: Often	I have defined SMART (Specific, Measurable, Achievable, Realistic, Trackable) goals for the New Year: Sometimes	I have defined SMART (Specific, Measurable, Achievable, Realistic, Trackable) goals for the New Year: Seldom	I have defined SMART (Specific, Measurable, Achievable, Realistic, Trackable) goals for the New Year: Never
I have a clearly defined wellness vision	I have a clearly defined wellness vision: Daily	I have a clearly defined wellness vision: Often	I have a clearly defined wellness vision: Sometimes	I have a clearly defined wellness vision: Seldom	I have a clearly defined wellness vision: Never
I am aware of what stresses me and fatigues me	I am aware of what stresses me and fatigues me: Daily	I am aware of what stresses me and fatigues me: Often	I am aware of what stresses me and fatigues me: Sometimes	I am aware of what stresses me and fatigues me: Seldom	I am aware of what stresses me and fatigues me: Never
I am confident I have the knowledge to make small changes to keep myself motivated towards my goals	I am confident I have the knowledge to make small changes to keep myself motivated towards my goals: Daily	I am confident I have the knowledge to make small changes to keep myself motivated towards my goals: Often	I am confident I have the knowledge to make small changes to keep myself motivated towards my goals: Sometimes	I am confident I have the knowledge to make small changes to keep myself motivated towards my goals: Seldom	I am confident I have the knowledge to make small changes to keep myself motivated towards my goals: Never

8. Starting and sticking with your goals for the New Year requires a shift in thoughts and and behaviors that take place over time. Where would you describe yourself in regards to reaching your goals?

9. This next part is a mandatory to complete to finalize your registration. Please read below:

PARTICIPANT’S RELEASE OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY AND
HOLD HARMLESS AGREEMENT

In consideration of being allowed use of the grounds and facilities of State College of Florida, Manatee-Sarasota (College) and participation in any College sponsored wellness programs, (Programs), wherever located, the undersigned participant acknowledges, appreciates and agrees that:
1.   The activities in the Programs including, but not limited to, travel related thereto involve the risk of serious injury and/or death and/or property damage and it is not possible to specifically list each and every individual risk. The undersigned participant expressly agrees that the following release, waiver and indemnity agreement is intended to be as broad and inclusive as is permitted by law of the state of Florida and that if any portion thereof is held invalid, it is agreed that the balance of this document shall continue in full legal force and effect.
2.   The undersigned participant HEREBY RELEASES, WAIVES, DISCHARGES, AGREES TO INDEMNIFY, HOLD HARMLESS AND COVENANTS NOT TO SUE THE COLLEGE, PARTICIPANTS, ORGANIZERS, SANCTIONING ORGANIZATIONS OR ANY SUBDIVISIONS THEREOF, OPERATORS, OWNERS, SPONSORS, ADVERTISERS, OWNERS, LESSORS, LESSEES OF PREMISES USED TO CONDUCT THE PROGRAMS AND EACH OF THEM, THEIR OFFICERS, DIRECTORS AND EMPLOYEES, ALL FOR THE PURPOSES HEREIN REFERRED TO AS “RELEASEES,” FROM ALL LIABILITY TO THE UNDERSIGNED PARTICIPANT, HIS/HER PERSONAL REPRESENTATIVES, LEGAL REPRESENTATIVES, ASSIGNS, HEIRS, AND NEXT OF KIN (EVERYONE), FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIMS OR DEMANDS THEREOF ON ACCOUNT OF INJURY TO THE PERSON OR PROPERTY OR RESULTING IN DEATH OF THE UNDERSIGNED PARTICIPANT (EVERYTHING), WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, WHILE THE UNDERSIGNED PARTICIPANT IS IN OR UPON THE PREMISES USED FOR THE PROGRAMS, AND/OR COMPETING, OBSERVING, WORKING FOR OR FOR ANY PURPOSE PARTICIPATING IN THE PROGRAMS. THE FOREGOING PROVISION ALSO INCLUDES, BUT IS NOT LIMITED TO, ANY TRAVEL RELATED THERETO AND THE UNAVAILABILITY, NEGLIGENCE OR DELAY IN THE PROVISION OF MEDICAL CARE.
3.   The undersigned participant hereby ASSUMES FULL RESPONSIBILITY FOR AND ALL RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE DUE TO THE NEGLIGENCE OF RELEASEES OR OTHERWISE while in or upon the premises used for the Programs, and/or competing, observing, working for or for any purpose participating in the Programs, including but not limited to, any travel related thereto and the unavailability, negligence or delay in the provision of medical care.
4.   The undersigned participant enters into this agreement for himself/herself, his/her personal representatives, assigns, heirs, and next of kin (EVERYONE).
5.   The undersigned participant has read and voluntarily signs this agreement, and further agrees that no oral representations, statements or inducements apart from the foregoing written agreement have been made. The undersigned participant acknowledges having had an opportunity to ask questions, consider this document, and obtain legal counsel for the same, and acknowledges that all questions have been fully answered to the participant’s satisfaction.
6.   The undersigned participant's participation in the programs is not a regular, direct or incident condition of the participant’s employment with the College. *This question is required.