Athlete Intake Questionairre

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Marital Status

Email

example@example.com

Employment

Home Phone

Cell Phone

USAT Number

Preferred Method of Contact

E-mailHome PhoneCell Phone

Height

Weight

What brand and type of smart watch do you use?

Do you have a Training Peaks Account?

YesNo

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Relationship

Please check all the apply

Do you use tobacco?

Do you use alcohol?

Brief description of past and current medical history, including any major illnesses, surgeries, or past medical problems and injuries:

Are you currently taking prescription medication?

YesNo

Primary Care Physician Name

First NameLast Name

Primary Care Physician Phone

Have you ever had a heart condition, chest pain, or high or low blood pressure, dizziness, recent surgery, pregnancy or injury? If so, please describe:

Have you experienced any emotional/mental health concerns that may affect your training? If so, please describe:

Any changes in your diet? Have you ever been diagnosed with an eating disorder?

Are you aware, through your own experience or doctor's advice of any other physical reasons you are exercising without medical supervision? Please explain:

Additional comments or concerns or anything else you would like me to know?

What sports have you participated in previously throughout your life?

What is your triathlon experience? How did you get started in the sport?

If you have previously raced in triathlon, what are your personal records in races and their corresponding distances?

How many hours a week have you trained previously?

Have you ever experienced overtraining symptoms? (chronic fatigue, lack of improvement in performance, etc.)

Have you ever incorporated strength training in your workout?

YesNo

What's your current resting heart rate?

How would you describe your current fitness level?

Describe your current training programs including how you track it (ex: Strava, Training Peaks, etc.)

Swim

Average pool swim pace (100/yd)

Please describe your swim history, strengths and areas for improvement.

Where and when do you have availability to swim?

Have you ever utilized structured swim sets

YesNo

What kind of bike(s) do you have:

Bike Equipment

What equipment do you use for indoor training

Smart Trainer (Kickr, Tacx, Saris)Bike RollerMechanical TrainerExercise Bike

Do you utilize any of the following online virtual programs?

What brand of running shoes do you use?

Have you ever experinced running injury (plantar fasciitis, shin splints, stress fractures

YesNo

Please describe your running history, where you normally run, terrain, type of running and any race experience.

How many miles do you put on your shoes before you replace them?

Please list running and fitness equipment you currently own.

What is/are your most important race(s)? What other races and goals do you have for the season? Do you have a goal time/place? Please describe.

Please list any upcoming races.

What is your favorite type of workout?

What are some types of training you avoid or don't do as much?

How can I best help you achieve your goals as a coach?

WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (“AGREEMENT”) I, THE UNDERSIGNED PARTICIPANT AND THE PARENT OR LEGAL GUARDIAN OF A MINOR PARTICIPANT NAMED BELOW, HEREBY AGREE AND MAKE THE FOLLOWING ACKNOWLEDGMENTS AND REPRESENTATIONS PURSUANT TO THIS AGREEMENT: I. PARTICIPATION.
I ELECT TO PARTICIPATE AS A MEMBER OF SCHUYLKILL ENDURANCE AND MULTISPORT LLC /SCHUYLKILL TRIATHLON CLUB (HEREINAFTER THE “CLUB”). I HEREBY REPRESENT THAT (I) I AM IN GOOD HEALTH AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE WITH THE CLUB; AND (II) I WILL NOT BE UNDER THE INFLUENCE OF ALCOHOL OR ANY ILLICIT OR PRESCRIPTION DRUGS THAT WILL IMPAIR MY ABILITY TO SAFELY PARTICIPATE IN CLUB RELATED ACTIVITIES. CLUB RELATED ACTIVITIES INCLUDE, BUT ARE NOT LIMITED TO, TRIATHLONS, DUATHLONS, OPEN WATER SWIMS, POOL SWIMS, STRENGTH TRAINING CLASSES, YOGA CLASSES, RUNS, BICYCLE RIDES, CROSS-TRAINING, AND CLUB SANCTIONED EVENTS (HEREINAFTER “CLUB ACTIVITIES”). II. ASSUMPTION OF RISK. I UNDERSTAND THAT
THERE ARE CERTAIN RISKS AND HAZARDS INVOLVED IN CLUB ACTIVITIES, WHICH INCLUDE HAZARDS ASSOCIATED WITH WEATHER CONDITIONS, PLAYING CONDITIONS (INCLUDING WATER CONDITIONS AND ROAD CONDITIONS), VEHICLE TRAFFIC, AND COLLISIONS WITH STATIONARY OBJECTS, ALL OF WHICH CAN CAUSE SERIOUS INJURY OR DEATH TO ME, OTHER MEMBERS, AND PARTICIPANTS. I ALSO UNDERSTAND AND ACKNOWLEDGE THAT PARTICIPATION IN TRIATHLON, DUATHLON, RUNNING, SWIMMING, CYCLING, STRENGTH TRAINING, CROSS TRAINING, AND YOGA INVOLVES RISK AND DANGER WHICH INCLUDES, BUT IS NOT LIMITED TO, THE POTENTIAL FOR DAMAGES FOR PERSONAL OR BODILY INJURY, DISABILITY, DEATH, LOSS OR DAMAGE TO PERSON OR PROPERTY, SICKNESS, DISEASE, PARALYSIS, DROWNING, AND EXPOSURE TO EXTREME CONDITIONS (HEREINAFTER THE “RISKS”). I UNDERSTAND THAT THE RISKS MAY BE CAUSED IYN WHOLE OR IN PART BY THE ENVIRONMENT, “ACTS OF GOD,” AND THE ACTION, INACTION, OR NEGLIGENCE OF: MYSELF, NON-PARTICIPANTS, CLUB PARTICIPANTS, OR THE RELEASED PARTIES (DEFINED BELOW). I HEREBY EXPRESSLY AND VOLUNTARILY CHOOSE TO ASSUME ALL SUCH RISKS AND RESPONSIBILITY FOR ANY DAMAGES, LIABILITIES, LOSSES, OR EXPENSES I INCUR AS A RESULT OF MY PARTICIPATION WITH THE CLUB (INCLUDING OPEN WATER SWIMS, BICYCLE RIDES, RUNS, STRENGTH TRAINING, YOGA, TRIATHLONS, AND ANY ACTIVITIES ARRANGED FOR BY MY CLUB FOR PRACTICE OR PLAY). III. RELEASE FROM LIABILITY. I AGREE THAT, IN CONSIDERATION FOR THE RIGHT TO PARTICIPATE AS A MEMBER OF THE CLUB, I RELEASE, DISCHARGE, AND AGREE NOT TO SUE THE CLUB, THEIR BOARD OF DIRECTORS, MEMBERS, OFFICERS, AGENTS, SERVANTS, ASSOCIATIONS, OR EMPLOYEES (HEREINAFTER {M1178569.1} “RELEASED PARTIES”) FOR ANY CLAIM, DAMAGES, COSTS, OR CAUSE OF ACTION THAT I HAVE, OR MAY HAVE, AS A RESULT OF INJURIES OR DAMAGES SUSTAINED OR INCURRED BY ME AS A RESULT OF MY PARTICIPATION WITH THE CLUB. THIS INCLUDES, BUT IS NOT LIMITED TO, THE NEGLIGENCE, BREACH OF CONTRACT, OR

WRONGFUL CONDUCT OF THE PARTIES THAT ARISES OUT OF CLUB ACTIVITIES. I FURTHER AGREE

THAT I SHALL HOLD HARMLESS AND FULLY INDEMNIFY THE PARTIES HEREBY RELEASED FROM ANY CLAIMS, DAMAGES, COSTS (INCLUDING ATTORNEYS’ FEES) IF I, OR ANYONE ON MY BEHALF, MAKES A CLAIM FOR LIABILITY AGAINST ANY OF THE RELEASED PARTIES. IV. ACKNOWLEDGMENT FOR MINOR CHILD (INITIAL HERE IF APPLICABLE_______). I AM THE PARENT OR LEGAL GUARDIAN OF THE BELOW-NAMED PARTICIPANT, AND I AGREE THAT THE PARTICIPANT MAY JOIN AND PARTICIPATE WITH THE CLUB IN ALL CLUB ACTIVITIES. ON BEHALF OF MYSELF AND THE MINOR PARTICIPANT, I HEREBY IRREVOCABLY AND UNCONDITIONALLY (I) AGREE TO ALL OF THE TERMS SET FORTH ABOVE IN SUBSECTIONS I, II, AND III OF THIS AGREEMENT, WHICH I FULLY INCORPORATE HEREIN, AND (II) AUTHORIZE THE CLUB OR ANY OF ITS DESIGNEES TO ARRANGE OR ANY NECESSARY MEDICAL TREATMENT FOR THE MINOR PARTICIPANT IF THE NEED ARISES. V. GOVERNING LAW. THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE WITH AND GOVERNED BY THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA. IF ANY PORTION OF THIS AGREEMENT IS FOUND TO BE VOID OR UNENFORCEABLE, THE REMAINING PORTIONS SHALL REMAIN IN FULL FORCE AND EFFECT. I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND THAT I UNDERSTAND EACH AND EVERY ONE OF THE ABOVE PROVISIONS IN THIS AGREEMENT, AND AGREE TO ABIDE BY THEM.

Date

Signature

Athlete Intake Questionairre

Emergency Contact Information

Medical History

Athletic History

Current Fitness

Swim

Bike

Run and Strength

Goals

Athlete Waiver