Coaching In-Take Form Step 1 of 13 7% How did you hear about coaching with Us?(Required)SelectRace CommunityWord of MouthRun Like a GirlFacebookGoogleInstagramOtherName(Required) First Last Email(Required) PhoneAddress(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)SelectMaleFemaleOtherHeight(Required)Weight(Required)Choose a Plan Package A – Programming Package B – Programming & Nutrition Package C – Programming & Strength Why are you seeking Jen as your coach? Health HistoryCurrent Injuries? Yes No If yes, please describePast Injuries Yes No Family History of Coronary Artery Disease? Yes No Fainting or Dizziness? Yes No Seizures? Yes No High Blood Pressure? Yes No Diabetes? Yes No Heart Attack / Chest Pain? Yes No High Cholesterol? Yes No Smoking (past or present)? Yes No If yes, please describeAlcohol/Drugs? Yes No Joint or Back Problems? Yes No Joint or Back Problems? Yes No Medication? Yes No Chance of being pregnant? Yes No Current Treatments? (Chiro, Physio etc.) Yes No If yes, please describe GoalsPrimary GoalDate of event DD slash MM slash YYYY Distance Secondary GoalDate of event DD slash MM slash YYYY DistanceLong Term GoalsWhat motivates you to train and work hard? What is your WHY for undertaking challenges?This is important to know because when things get tough, you want to know WHY you are putting in the time and effort to training and to your goals. We can circle back to our WHY to help us through.Race ScheduleFitness ExperiencePast Races / Personal BestsInterestsWeekly mileage or weekly hours training currentlyNumber of Years Training Do You…Check all that applyHave weight training experience? Yes No If yes, please explainBelong to a gym? Yes No Currently following a structured weight training plan designed specifically for you? Yes No If yes, please explainWork with a personal trainer or attend group strength classes? Yes No If yes, please explainDo you attend any group classes or group training sessions? Yes No If yes, please explainAccess or participate in a Spin or Indoor Cycling Program? Yes No If yes, please explainFor Cyclists: do you own a smart trainer (such as a Wahoo Kickr or Tacx Trainer) for indoor riding? Yes No If yes, please explainFor Cyclists: Do you currently use a program such as Zwfit or Trainer Road? Yes No If yes, please explainWhat is your preferred rest day? Outline Your Current Work & Training ScheduleMondayTuesdayWednesdayThursdayFridaySaturdaySunday Run or Bike SpecificWhat is your longest RUN currently?What is your current weekly mileage?What is your longest BIKE currently?What is your current weekly mileage?Do you have experience with a heart rate monitor?If yes, what is your resting heart rate?Max heart rate?Do you have experience doing speed work?If yes, describeDo you have experience hill training?What do you consider your training strength?(ex. flexibility)What do you consider to be your training weaknesses?(ex. hills)Are there certain types of training you enjoy?(ex. long & slow runs)Are there certain types of training you dislike?(ex. speed work)Do you train with a partner or a group? How often? Type of workout? Recent Competition Times & Results10km½ MarathonMarathon50kmUltraStage RaceWill you have access to the following terrain? Road Treadmill Trails Grass Field Check all that apply Cross TrainingDo you enjoy the following activities or currently participate in them? Option one Option two Describe what sort of outdoor terrain you are able to access? Ex – length of hills, mountains, only roads etc.Other activities?What type of fitness equipment do you have at home?ie – treadmill, body ball, free weights, skipping rope, etcDo you have a Weight Vest and/or Ruck Backpack? Yes No Adventure RacersCheck which applies I own my own bike. I currently do BRICK workouts and LONG workouts as part of my training. Describe a typical Brick workout that you would doWhich discipline(s) would you consider to be your strength?Which discipline(s) would you consider to be your weakness(es)? NutritionAre you pleased with your present eating habits?Are you following a special diet?If yes, please explainWas your diet recommended by a health professional?Have you ever been on a diet to lose weight?TobaccoSoda / PopCoffeeAlcoholRecreational DrugsHow is your appetite?Who usually prepares the food at home?How many meals per week do you eat at a restaurant?How many times per week do you eat fast food?What time of day are you most hungry?What eating habits would you like to eliminate, modify, or incorporate into your diet?Describe your typical daily dietWhat do you typically eat before a race/training session?What do you typically eat after a race/training session?How much water do you drink each day?On average, how many of hours of sleep do you get each night?Do you wake feeling rested?Do you require assistance with your nutrition? Liability ReleaseIs there anything else that would be important for your coach to know when designing your program and training plan? The more information that you can provide will assist your coach in assessing and making recommendations and improvements to your training.The information that I have given is true and correct to the best of my knowledge. Should any conditions change, I agree to notify my coach immediately.(Required) The information that I have given is true and correct to the best of my knowledge. Should any conditions change, I agree to notify my coach immediately.(Required) Par-Q & YouHas your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(Required) Yes No Do you feel pain in your chest when you do physical activity?(Required) Yes No In the past month, have you had chest pain when you were not doing physical activity?(Required) Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?(Required) Yes No Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?(Required) Yes No Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?(Required) Yes No Do you know of any other reason why you should not do physical activity?(Required) Yes No I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.(Required) I agree I do not agree Name(Required) First Last Date(Required) DD slash MM slash YYYY Witness(Required) WaiverAre you over the age of 19?(Required) Yes No Please acknowledge your minimum monthly commitment to coaching.(Required) Level I: 4-month commitment Level II: 6-month commitment Level III: 6-month commitment Do you agree to giving a full 1 month (30 day) email notice before suspending or cancelling coaching.(Required) YesI CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS RELEASE AGREEMENT PRIOR TO SUBMITTING IT, AND I AM AWARE THAT BY SUBMITTING THIS RELEASE AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATTIVES MAY HAVE AGAINST THE RELEASEES.(Required) I confirmParticipant Name(Required) First Last Signature(Required)Date DD slash MM slash YYYY Untitled
