Name Age ______ Email Phone E

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Name _____________________________________

Age ______

Email _____________________________________

Phone _____________________

Emergency Contact __________________________

Emergency Contact Phone ___________________

Running Experience 1. Are you, or have you ever been, a regular runner, run/walker? 2. If so, briefly describe the nature and extent of your run or run/walk regimen (e.g.; how many days per week, typical distances you cover, pace (if known), etc.). 3. Have you ever trained for a race? If so, what distance(s) and how would you describe your training program? 4. What is your running goal (e.g.; run faster, don’t run out of energy, just finish without injury, etc.)? 5. Do you have a history of running-related injuries? If so, briefly describe. 6. Is there anything about running that makes you nervous about training on a regular basis (e.g.; injuries, early mornings, not knowing about the right gear, worried about being “too slow”, etc.)? 7. What do you hope to gain from run coaching (e.g.; run your first 5k, run a marathon, increase selfesteem, etc.)? Physical Activity Readiness 1. Have you been diagnosed with any medical condition that we should be aware of (heart condition, diabetes, cancer, auto-immune disorder, arthritis, etc.)? If yes, please explain. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2. Do you have any joints that bother you or have bothered you in the past (neck, back, shoulders, elbows, wrists, hands, hips, knees, ankles, feet)? ___________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. Tell us about any accidents, strains, sprains, broken bones, or surgeries you have had, no matter how old you were or how insignificant you might think it was/is. _________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

4. Are you taking any medications? If yes, please list. ___________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Health and Wholeness asks that you get written permission from a doctor before participating in Running Club/Coaching. If you choose not to get written permission from a doctor, by signing below you acknowledge that we have asked you to do so, and you also assume the risks for any injuries arising from undertaking any and all exercises due to a known or unknown medical condition. By signing you also acknowledge that you understand all forms of exercise have inherent risks, you accept that risk, and that will not hold Health and Wholeness responsible for any injuries resulting from your participation in Running Club/Coaching. Refunds, and Finality of Sale _______ I acknowledge that after paying for any Health and Wholeness services I have 72 hours to request a refund for any services not yet rendered. After that 72-hour period I acknowledge that Health and Wholeness does not offer refunds for services I have purchased. Furthermore, I will not seek to be reimbursed by Health and Wholeness or any of their coaches for any expenses I may have incurred as a result of my coaching. Expiration Date, Cancellation Policy and Right to Stop Services _______ I understand Health and Wholeness requires 24-hour notice if I wish to cancel any scheduled appointment, and if I fail to give proper notice it will result in a forfeiture of that session. I also understand any service I purchase carries a 1-year expiration date. I also understand Health and Wholeness reserves the right to stop services if I fail to make payments on time.

Signature: __________________________________

Date: _____________________