Breath Runner Intake and Liability Waiver Form

Breath Runner

A Division of AquaTerra Coaching, LLC
Run 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*
USATF Membership # (if applicable)
Leave Blank if not a member of USA Track & Field
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:

	Never	Rarely	Sometimes	Often	Very Often
Chest pain
Feeling tense
Blurred vision
Dizzy spells
Feeling confused
Sudden faster/deeper breathing (not associated with exertion)
Short of breath
Tight feelings in the chest
Bloated feeling in the stomach
Tingling fingers
Unable to breathe deeply
Stiff fingers or arms
Tightness/tight feelings around the mouth
Cold hands or feet
Heart palpitations (sudden rapid and/or extra strong heart beats)
Feelings of anxiety

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

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Run
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

Breath Runner

Run Intake Form

Health and Medical

The following questions are ranked from:

How confident are you that you can:

MOOD STATE:

Dietary Concerns

PARA ATHLETES ONLY

Lifestyle Information

Training and Exercise History

Run Training

Strength Training

Mental Readiness/Personality