AQTC Cyclist Intake and Liability Waiver Form

AquaTerra Coaching, LLC

Cycling Training
Cyclist Intake Form

Required items marked with red asterisk. All others optional. You will be able to save your answers and return later if necessary.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone Number*
Home Phone Number
Work Phone Number
Primary Email*
example@example.com
Secondary Email
Optional
What is the best way to contact you?*

Phone callEmailTextMessengerOther
Emergency Contact Name*

First NameLast Name
Emergency Contact Mobile Phone Number*
USA Cycling Membership # (if applicable)
Leave Blank if not a member of USA Cycling
USAT Membership # (if applicable)
Leave Blank if not a member of USA Triathlon

PARA ATHLETES ONLY

All items are optional to answer, but extremely helpful
USAT Open Classification

YesNo
USAT / WTC Classification
Brief description of challenge(s)
Physical, Neurological, etc.
Adaptive equipment needed
Prosthetics, Wheelchair, Guide, etc.
Prosthetist/Medical Team
Name(s) and contact info
Travel restrictions
Personal and/or Equipment

AquaTerra Coaching, LLC

Waiver and Release from Liability
A check mark below indicate I have read, agree with and understand the following:*

I have read, understood and agree to the terms outlined in the WAIVER AND RELEASE FROM LIABILITY.I agree and verify that all of the information that I have given AquaTerra Coaching, LLC and its representatives is accurate, up-to-date, and without the omission of any known medical issues.I agree and verify that if I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold AquaTerra Coaching, LLC, its principles and representatives, harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.I agree to keep AquaTerra Coaching, LLC apprised of any changes or upcoming changes concerning my physical health and personal information.I understand and agree that it is my responsibility to let AquaTerra Coaching, LLC know if I find myself in any pain or discomfort before, after, or during any Activities and Events.If I do require medical treatment or attention while or after participating in Activities and Events. I agree that the medical costs are mine and mine alone and hold AquaTerra Coaching, LLC, its principles and representatives, blameless from any charges, fees, or costs that my treatments may incur.* I agree, and it is my intent, to electronically sign this document by e- signature. By submitting this e-document to AquaTerra Coaching, LLC in this way, I and am affirming to the truth of the information contained therein, and that I understand and agree that this e-signing and submitting is the legal equivalent of having placed my handwritten signature and affirmation on the submitted document in accordance with New York State and Federal laws.
Name

First NameLast Name
Today's Date*

MonthDayYear
Date
Should be Empty:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Mornings
Afternoons
Evenings
All Day

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Bike
Strength
Cross Training

	Not Confident	Slightly Confident	Confident	Mostly Confident	Extremely Confident
Self-Awareness
Consistency
Ability to complete my “A” Race
Ability to set goals and targets
Ability to follow through with goals
Use of visualization/imagery to prepare for a race
Use of self-talk/thought control
Ability to pay attention/focus under stress
Ability to endure peak uncomfortability
Ability to excel under pressure
Ability to make decisions under stress
Ability to take recovery days without guilt

AquaTerra Coaching, LLC

Cyclist Intake Form

Health and Medical

Dietary Concerns

PARA ATHLETES ONLY

Lifestyle Information

Cycling Goals

Training and Exercise History

Cycling Experience

Strength Training

Mental Readiness/Personality