Dear Runner,

Please complete this questionnaire, and return it to:

Vermont Running Coach
34 Valley View Drive
Milton, Vermont, 05468

Your Personal Running Story .............................................................Date_________

Name_____________________________

Age__________________Sex_______________

Address______________________________________________________

Town________________________State_______________Zip_____________________

Home Phone__________________________Work Phone_________________________

Email Address______________________________________

Height_____________Weight___________________

Medications(if any)_______________________________

Your assessment of your health_____________________________________________

Health Risks_____________________________________________________________

Injury Status and description________________________________________________

Years Running_____________Current Miles Per Week________________________

Other Sports and Cross Training____________________________________________

Road Racing Background?_________________________________________________

Recent Race Times

Date Distance Time
1.
2.
3.
4.
5.
6.

Personal Records(Bests) Date Time
5k
10k
15k
Half
Full
Other

List or describe your goals and racing plans for the next year:______________________

What are some problems or challenges you would like to overcome for your running or your racing_____________________________________________________________

What is your goal in having a running coach?__________________________________

________________________________________________________________________

Describe your most recent training period(last 3-4 weeks). Use the information from your diary, include miles, paces, types of workouts, races and effort levels:
1.Mon. Tu. Wed. Thurs . Friday Sat. Sun

2.

3.

4.

Please use this space to address any other subjects you would like to let VRC know about, or address during your coaching period.

Please be advised that all information collected on this form is confidential and is intended for use as a training aide in assessing your fitness and capacity to handle the stresses of increased running.

Waiver and Informed Consent

Your Responsibilities:

· Keep in contact with VRC about the status and progress of your training. Use a log book to record all relevant data and provide that information to VRC on a regular basis through phone or email communications.

· Agree to inform the VRC if you will miss an appointment within 24 hours of the time

· Agree to inform VRC of any and all injuries and illnesses as soon as possible

· Agree to inform VRC of any questions or concerns in a timely fashion

VRC Responsibilities:

· Create a personalized training schedule, provide coaching in the art and science of running, and give the runner ample opportunity for communications and assistance.

· Agrees to be available for phone coaching and to respond to email inquries in a timely fashion.

· Agrees to provide assistance in injury diagnosis and rehabilitation and to suggest courses of action and professional treatments as appropriate.

I understand that running is inherently a potentially dangerous activity. I understand the risks involved with running and with undertaking an increased level of activity. I accept responsibility for my personal safety and health. In consideration of entering into this training program I and my heirs, executors and administrators waive and release any and all rights and claims of damage I may have against Vermont Running Coach LLC and all parties involved in the training program for any and all injuries suffered by me as a result of running or training.

Date____________________ Signature________________________________

VRC_________________________________________-