Join | Coach Cary

Name*

First Last

Preferred Name

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone (Cell)*

Phone (Home)

Email*

Birthdate*

Age*

Height*

Weight*

Occupation*

Work Hours per Week*

Marital Status

Number of Children

Ages

Emergency Contact*

First Last

Relationship*

Emergency Contact Phone*

Other Contact Info (Home, Email)

How did you hear about us?

Sports Background & Training Information

What do you want from a coach?

What do you consider your strengths as an athlete? Weaknesses? (Please list at least 2 of each):

Sports Accomplishments of which you are proudest:

Years Competing:

Sports in which you compete/have competed:

Other sports in which you have participated/currently participate (not competitively):

Swimming History

Most yards swum in a single workout:

7 day period:

Are you satisfied with your swim stroke?

Yes
No

Please explain

Have you swum with a Masters group?

Yes
No

Please explain:

Have you raced in a swim meet(s)?

Yes
No

Please explain

What length pool do you have access to?

25 yd
25 meter
50 meter

Cycling History

Most miles ridden in a single ride:

7 day period:

What type of bike do you own (road, tt, mountain, cross, etc.)?

Are you satisfied with your bike fit/position?

Yes
No

Please explain:

Do you have a stationary trainer?

Yes
No

Brand/type:

Do you have a power meter?

Yes
No

Brand/type:

Do you have a HR monitor

Yes
No

Brand/type:

Have you raced in bike specific races(s)?

Yes
No

Please give details:

Running History

Most miles runs in a single run:

7 day period:

Are you satisfied with your run mechanics/form?

Yes
No

Please explain:

Do you have a HR monitor?

Yes
No

Brand/model:

Do you trail run:

Yes
No

Give details:

Do you have a treadmill?

Yes
No

Give details:

Do you have access to a track?

Yes
No

Give details:

Have you raced in a running race(s)?

Yes
No

Give details:

Strength Training History

Do you currently strength train?

Yes
No

Give details:

Do you have access to a gym?

Yes
No

Summarize equipment available (free weights, TRX, kettlebells, etc.):

Nutrition History

Are you satisfied with your nutrition/diet in daily life?

Yes
No

Please explain:

Are you satisfied with your nutrition/diet for racing?

Yes
No

Please explain:

Have you worked with a nutritionist/dietician?

Yes
No

Please explain:

Hours available to train Monday:

Hours available to train Tuesday:

Hours available to train Wednesday:

Hours available to train Thursday:

Hours available to train Friday:

Hours available to train Saturday:

Hours available to train Sunday:

On average how many hours per week have you spent training in the last month (or several months, if now is not a typical training season)? Please give details:

How many days off from training do you currently take per week?

Ideally how many days off would you take?

What is your waking pulse (if known)?

Is this high or low for you (if known)?

Racing and Performance Goals

Below please list the events you are currently considering for the coming season (and beyond, if applicable) and status (i.e. registered, in lottery, interested...):

High priority events (typically 1-3 events in a given season):

Please include date, event/distance, goal, status.

Lower priority events:

Please include date, event/distance, goal, status.

What is your number one goal this season (please be specific)?

Health/Medical Information

Height*

Weight*

Weight goal, by when?

% Body fat (if known):

% Body fat goal, by when?

Primary Care Physician Name:*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Please list any current illness, recent injuries, recent surgeries, or past medical problems of note:

Do you have, or have you had, any of the following?

Heart disease:*

Yes
No

Heart attack:*

Yes
No

Heart surgery:*

Yes
No

Heart mummur:*

Yes
No

Hypertension:*

Yes
No

Thyroid problems:*

Yes
No

High cholesterol:*

Yes
No

Eating disorder:*

Yes
No

Asthma:*

Yes
No

Diabetes:*

Yes
No

Epilepsy:*

Yes
No

Anemia:*

Yes
No

Stress fracture:*

Yes
No

Concussion:*

Yes
No

Joint problems:*

Yes
No

Muscle cramps:*

Yes
No

Please give details for any “Yes” answer above:

Please list any medications you take on a regular basis (prescription & non prescription):*

Please include the medication, dose, frequency, and reason.

Any special medical needs or information we should be aware of?

Physical Activity Readiness Questionnaire

Has a doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

Yes
No

Do you feel pain in your chest when you perform physical activity?*

Yes
No

In the past month have you experienced any chest pain?*

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

Do you have a bone or joint problem that could be made worse by the proposed physical activity?*

Yes
No

Has your doctor ever recommended medication for high blood pressure or for a heart condition?*

Yes
No

Are you aware, through your own experience or a doctor’s advice, of any other physical reasons against your exercising without medical supervision?*

Yes
No

If you answered “yes” to any of the above questions, please explain (and please note, that in this case, we will require medical clearance from you physician that the proposed training is acceptable/allowable for you):

Informed Waiver & Release of Liability

I, __________________________(“Client”) have hired C2 Fitness LLC, a Colorado limited liability company (“Company”) to provide athletic coaching, training and nutrition advice based on my goals and objectives that I provided to the Company (the “Advice”).

By my signature below, I hereby affirm and acknowledge the following:

- I understand the Advice is just that – advice – and it is not a directive or requirement that I follow any of it, and if I choose to undertake any activities or behaviors that are in any way related to the Advice, all such activities and behaviors are of my own volition and discretion. I understand I am voluntarily participating in physical activities based on the Advice and that any inherent risks, which include serious injury or death, associated with these activities are completely under my control and use of common sense.

- The Advice has been provided to me based on my representation to the Company that I am in good physical, mental and emotional health

- I agree to waive, release, indemnify and hold the Company, its directors, managers, members, owners, agents, officers, and employees harmless against loss (including reasonable attorney’s fees and costs incurred) from any and all claims, demands, rights or causes of actions of any kind or nature that may hereafter at any time be made or brought by me or on my behalf, or as a result of my injury or death, and for any known or unknown, foreseen or unforeseen bodily or personal injuries, damages to property and consequences thereof, which may be sustained by me as a direct or indirect result of my voluntary participation in activities or behaviors in any way related to the Advice.

- I further waive any and all of the foregoing described claims against the Company, its directors, managers, members, owners, agents, officers and employees to the fullest extent permitted by law.

- I declare that I have read, understood, and agree to the contents of this Informed Waiver & Release of Liability Agreement in its entirety.

I agree to use electronic records and signatures*

Agree

I have read and agree to the terms in the Informed Consent & Waiver*

Yes

Signature*

Recurring Payment

Monthly Coaching Fee

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Get Started

Sports Background & Training Information

Swimming History

Cycling History

Running History

Strength Training History

Nutrition History

Racing and Performance Goals

Health/Medical Information

Physical Activity Readiness Questionnaire

Informed Waiver & Release of Liability

Recurring Payment