Women Run PDX Questionnaire & Contract

Runner Questionnaire & Contract
Thank you for choosing to train with Women Run PDX!

Please take some time to fill out this runner questionnaire with as much detail as possible. It covers:
- Your personal details
- Your injury history
- Your running experience and goals
- The legal part: our contract
Your information will be kept confidential.

We appreciate your taking the time to help us build the best possible program! You can save and come back to it if you can't finish it right now.

When you submit the form, you'll get taken to a payment page to finalize your registration.
Personal Details
Full name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Mobile number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact - name, relationship and phone number:*

Medical / Injury History
Are you currently under the care of a physician or therapist for any injury or medical condition? Provide details:
Do you currently have, or have you had in the past, any running injuries or pain with running? Please provide details and dates:
If you answered yes to either of the questions above, how does this injury, medical condition or pain affect your training?
Any other relevant health or injury history that may affect your participation in the group or that we should be aware of?

Your Running Experience & Goals
How long have you been running consistently?
What's your current average weekly mileage?
How long (in time or distance) is your current long run?
What's your usual pace for easy runs?
Do you have experience with speed, hill, or tempo workouts?
What are you hoping to learn or gain from this program?
Please tell us about your current running goals, including any races you may have on the calendar:
Which option are you signing up for? (If registering for one day only, use promo code SATURDAY at the checkout)*

The full program: Tuesdays & Saturdays ($150)Tuesday track only ($100)Saturday runs only ($100)

Release & Waiver of Liability
Waiver of Liability, Assumption of Risk, and Indemnity Agreement Waiver:

I wish to participate in the Women Run PDX running program offered by coaches Heini Tallent and Nicole Mueller. In consideration of being permitted to participate in this program I, for myself, my heirs, personal representatives and assigns, do hereby release, waive, covenant not to sue and discharge Coach Heini Tallent and Coach Nicole Mueller from liability from any and all claims including the negligence of Heini Tallent or Nicole Mueller resulting in any personal injury, accident, illness, or property loss arising from my participation in the Women Run PDX training program.
I agree - type full name:*
Date*

MonthDayYear
Assumption of Risks:

I understand that participation in running and conditioning programs carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries.

I understand that running is a potentially hazardous activity and certify that I am in good health and physically fit to enter into a training program. Heini Tallent and Nicole Mueller recommend a physician's examination and approval before starting any new running or fitness regimen, and I understand that if I choose not to see a physician prior to beginning a running program I participate entirely at my own risk.

I acknowledge that I am aware of the many risks involved in athletic training in general and running training specifically, which include by way of example and not limitation: 1) minor injuries such as scrapes, bruises, sprains and strains, 2) more serious injuries such as joint, muscle and bone injuries, concussions and other head injuries, heat related injuries such as heat stroke and heat exhaustion, dehydration and overhydration conditions such as hyponatremia, and catastrophic injuries and conditions such as heart attacks and other conditions or injuries which could be fatal.

I have read the previous paragraphs and I know and understand these and other risks that are inherent in training for and participating in road, trail and track running and racing and any conditioning and cross training activities associated with that training. I understand that I am not obligated to perform nor participate in any activity that I do not wish to do. I also understand that it is not possible to guarantee or give assurance of a successful result, no individual physical assessment will be performed, and that any recommendations given are not meant as a substitute for medical advice. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
I agree - initial:*
Indemnification and Hold Harmless:

I also agree to indemnify and hold harmless Coach Heini Tallent and Coach Nicole Mueller from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the Women Run PDX training program.
I agree - initial:*
Severability:

The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I agree - initial:*
Acknowledgment of Understanding:

I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
I agree - type full name:*
Date*

MonthDayYear
Should be Empty:

Runner Questionnaire & Contract

Personal Details

Medical / Injury History

Your Running Experience & Goals

Release & Waiver of Liability