East River Park Track Club Coaching Questionnaire
Members may print this form, complete it, sign the release at the bottom and return it to a club coach, or mail it to the club's mailing address. We will require a printed copy with a signature on file.
To speed up the process, you may scan and email the questionnaire to info@eprtc.org . The club will require an original signed copy for it's records.
Download the Word document version for better printing results
East River Park Track Club, Inc.
P.O. Box 444
New York, NY 10002
email: info@eprtc.org
phone: (646)403-4758
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)
Event, Distance, Pace or Time and 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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Additional comments or concerns__________________________________________
_________________________________________________________________________
________________________________________________________________________
EAST RIVER PARK TRACK CLUB 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 East River Park Track Club’s Training Program. I, for myself, my heirs, personal representatives and assigns, do hereby release, waive, covenant not to sue and discharge East River Park Track Club from liability from any and all claims including the negligence of East River Park Track Club resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in East River Park Track Club'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 East River Park Track Club 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 East River Park Track Club’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:
- To design an individualized training schedule, provide motivation and feedback, technical assistance, racing guidelines, and counseling to each runner based on his/her goals and fitness level.
- To be available by phone during scheduled office hours or by email for consultation.
- To assist you in obtaining diagnosis or treatment if injured. To write a training rehab plan to assist you in maintaining your present fitness level and to return to running as soon as possible.
Athletes Responsibilities:
- Keep the coach up to date on how you are responding to the training by maintaining your training log.
Notify the coach as soon as possible:
- When it seems like you may have an injury or, the beginning symptoms of illness
- If you need to miss or modify a training session or scheduled race.
- When you plan to opt out of personal coaching for a period of recovery or or other activities.
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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