Team Oregon Coaching Questionnaire

Print this form, fill out, sign the release at the bottom and return it with your check to Team Oregon, 22066A SW Grahams Ferry Rd, Tualatin, OR 97062. Our fee is $100. per session. (see description on the COACHING web page). Pay online at http://www.teamoregon.com/commerce/teamore.html . Checks payable to Team Oregon.

For fast response, paste this form into your mail program, fill it out and email it to us. We will still need a printed copy with a signature mailed to us.

Team Oregon

22066A SW Grahams Ferry Rd

Tualatin OR, 97062

email:

phone: (503)-319-8348



Personal Running History

Name_______________________________________________Date_______________

Age______________________________Sex__________________________________

Address________________________________________________________________

City________________________________State___________________Zip__________

Home Phone______________________Work Phone____________________________

Email Address_____________________Fax Number___________________________

Height____________________________Weight_______________________________

(If you know)

% Body Fat___________Resting Heart Rate (HR)__________Maximum HR________

Medications____________________________________________________________

Current State of Health__________________________________________________

If currently sick or injured, describe difficulty and date of onset__________________

_____________________________________________________________________

Health Risks (i.e. family history, chronic disease, etc.)_________________________

_____________________________________________________________________

Recent Running Injuries including date_____________________________________

______________________________________________________________________

How long have you been running?__________________________________________

Previous exercise or competitive history_____________________________________

______________________________________________________________________

Racing Experience None______Beginner_____________Experienced____________

Current Racing ( List races in last 6 months)

Distance Pace or Time Date





Personal Bests (List your best performances)

Distance Pace or Time Date





Running Interests

_______Fitness and Fun

_______Recreational or Social Racing

_______Racing for Improved Performance

_______Racing for Age Group or Other Awards

List your running and racing goals(future races, dates & goal times)

_________________________________________________________________________

_________________________________________________________________________

Describe any previous problems with racing or training___________________

_________________________________________________________________________

_________________________________________________________________________

Why are you seeking Personal coaching____________________________________

_________________________________________________________________________

Describe your most recent 4 weeks of training in detail. List the miles or time spent running, your pace or heart rate, the surface or terrain (track, road, bike path, bark chips, trails, flat, hilly, rolling etc.)and any supplemental or additional training (weights, stretching, cycling. swimming, aerobics etc.) Include any races run.

Example

Week: 10/20/04

Sunday: 4 mi @ 8:30 pace on rolling road, stretching, 20 min weights

Week:

Sunday:

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Saturday:

Week:

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Week:

Sunday:

Monday:

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Additional comments or concerns__________________________________________

_________________________________________________________________________

________________________________________________________________________

TEAM OREGON FITNESS/ATHLETICS COACHING

In order to help us plan a fitness/athletic program for you, it is necessary to evaluate some of your health and lifestyle history and practices as well as your present state of fitness. The questions need to be answered to the best of your ability. The information gathered will be used only in making recommendations for your program. Your individual data will be kept confidential.

CONSENT AND RELEASE

Waiver: In consideration of being permitted to participate in Team Oregon’s Training Program. I, for myself, my heirs, personal representatives and assigns, do hereby release, waive, covenant not to sue and discharge Team Oregon from liability from any and all claims including the negligence of Team Oregon resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in Team Oregon's Personal Training Program.

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 know that running is a potentially hazardous activity and certify that I am in good health and physically fit to enter into a training program. I acknowledge that I am aware of the many risks of injury or other conditions involved in athletic training in general and running training specifically, including conditions or injuries which could be life threatening. I have read the previous paragraphs and I know, understand, and appreciate 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 hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD HARMLESS Team Oregon 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 Team Oregon’s Training Program.

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

Responsibilities: I also understand and accept the following responsibilities:

Coaches Responsibilities:

Athletes Responsibilities:

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity, and responsibility agreement above, 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.

____________               ___________________________________________

       Date                                            Participant's Signature

                                                   (Parent or Guardian if Under 18)

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