Training With Sue

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Name

Address

City

State

Zip

Primary Phone

The phone listed above is my

Cell Phone

Home Phone

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Age

Date of Birth

How did you hear about us?

Is this your first triathlon?

Yes
No

If no, please indicate what it was and where.

Do you currently exercise?

Yes
No

If yes, what do you do and the approximate date you first began your program?

Check the box that most accurately describes you

I currently am a lap swimmer
I used to swim laps. I have a pretty good crawl stroke (freestyle)
My crawl stroke is so-so, but I don't know how to breathe
I am not afraid of the water, but I cannot do the crawl stroke
I do not swim. I have not had a bathing suit on since the Eisenhower administration!

When it comes to biking

I have a bike I ride on the roads
I have a bike and I prefer the trails
I am apprehensive about riding a bike
I feel confident on a bike, but I don't have one

When it comes to running

I consider myself to be a runner
I do not run, but I would like to start
I would like to run a bit and walk a bit
I would prefer to walk

HEALTH QUESTIONNAIRE
Please answer the following questions by checking Yes or No

Have a family history of heart disease?

Yes
No

Have high blood pressure?

Yes
No

If yes, are you on medication?

Yes
No

If yes, is it a beta blocker?

Yes
No

Do you smoke?

Yes
No

Do you take any medication?

Yes
No

If so, please explain:

Do you have diabetes?

Yes
No

Do you have chronic joint or muscle pain?

Yes
No

If yes, please explain:

Could you be pregnant?

Yes
No

Have you been pregnant in the last three months?

Yes
No

Has a doctor ever
suggested you limit your physical activity?

Yes
No

If yes, please explain:

Is there anything else I should know about your health history?

Yes
No

If yes, please explain:

It is recommended that everyone get a complete physical before starting a program of physical activity

All the information on this form is correct to my knowledge.

Yes
No

Please retype your name:

Date:

WAIVER AND RELEASE FROM LIABILITY:
PLEASE READ CAREFULLY

I acknowledge that training for a triathlon, and other endurance sports to be a test of physical and mental limits, and carries with it the potential for serious injury. I hereby assume the risk of participating in this program, in the triathlon and in the training of said triathlon. I certify that I have not been advised against participation by a qualified health professional.

I agree that prior to participating in the event or a training session I will inspect my equipment, and areas to be used and if I believe any are unsafe I will immediately advise the person supervising the event activity, facility, or area. I waive, release and discharge Susan Waldrop, the USAT, and all facilities used, from any and all claims, losses, or liabilities associated with participation in this program.

I acknowledge that there may be traffic or persons on the course route, and I assume the risk of running, biking and swimming in a race or while training. I also assume any and all other risks associated with participating in this triathlon program organized by Susan Waldrop including but not limited to falls, contact and/or effects with other participants, effects of weather including heat and/or humidity, defective equipment, the condition of the roads, and water hazards. All such risks are known and acknowledged by me.

I grant permission for the use of my name and/or likeness relating to my participation in this triathlon program, and I waive all right to any future compensation to which I may otherwise be entitled as a result of the use of my name or likeness.

I HEREBY AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER,
I HAVE READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENT.

Yes
No

PLEASE RETYPE YOUR NAME . THIS WILL BE YOUR OFFICIAL SIGNATURE FOR THE WAIVER RELEASE.