Registration and Release Form
EZ8 Runners

  

  Please complete This Page now and send by PDF file to kathy@ez8dc.com or mail to:

 EZ8 DC
Attn: Kathleen Pugh
1016 Constitution Avenue. NE
Washington, DC 20002

CALL 202-309-7508 with any questions. 
Please make check payable to: Kathleen Pugh or pay via Paypal to kathy@ez8dc.com.

All payments must be received by the first day of the program.

Name:______________________________________
Street:______________________________________
City:_______________________________________
State:______________________________________
Zip:_______________
Date of Birth ___/___/___

Emergency Contact and phone number_________________________
Home Phone (_____)_____________Work Phone (_____)_____________
Fax Number (___)_______________________
E-mail _________________________________@_____________
I rate my current fitness level as a _____ (1-10), ten being high.
I was referred by ______________________________.
My main goal is to ________________________________________________________   

Confirmations and detailed instructions will be mailed prior to the start of the EZ8 Running Program. Waiver must be signed prior to participation.

 MEDICAL HISTORY

1. What is the date of your last physical exam?
2. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? 
Yes     No                                                   
    If yes, list medication:  _____________________                                    
3. Do you take any prescribed medication on a permanent or semi-    permanent basis?     Yes     No 
If yes, list medication:  _____________________
4. Do you have a seizure disorder (epilepsy)? Yes     No
5. Do you have diabetes? Yes     No
6. Have you ever been found to be anemic (low blood count)? Yes     No
7. Do you have High Blood Pressure (hypertension)? Yes     No
8. Do you have or have you ever had the following diseases?
    Heart Disease:   Yes     No
    Lung Disease:    Yes     No
    Kidney Disease: Yes     No
    Liver Disease:    Yes     No
9. Do you have asthma? Yes     No
10. Have you ever had a severe neck injury?
       Describe: ________________________
11. Have you ever been knocked unconscious? 
Describe: ____________________________
12. Do you wear glasses or contact lenses? Yes     No
13. Have you had a broken bone or fracture in the past 2 years? 
Describe: ________________________
14. Have you ever injured your back?  Yes    No
Describe: _________________________
15. Do you have back pain? 
Never     Seldom     Occasionally     Frequently
16. Have you had knee pain in the last 2 years? 
Describe: _________________________
17. Do you have other physical conditions, which cause pain? 
Describe: _________________________
18. Detail any surgical procedures: ____________________
19. What are your goals for the next three months?
20. Have you had your body fat tested? Yes    No
If yes, what percent is it? _______________
21. Are you training for a specific event? Yes    No
If yes, explain: _______________________
22. What do you think your timed mile will be? ____________
23. How much have you been running lately? ______________

  

NOTICE: It is wise to seek your doctor’s advice before beginning any health/fitness/nutrition program!

RELEASE

This release is entered into between the undersigned and The EZ8 DC company, its officers, affiliates, and executors. The purpose of the EZ8 DC Company is to provide fitness instruction and coaching for various levels of athletes/individuals.

   
The undersigned hereby acknowledges that the following was explained to me and/or agree to the following:

1. Acknowledges that Kathleen Pugh is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
2. Acknowledges that Kathleen Pugh will provide fitness instruction and coaching to the undersigned, but that Kathleen Pugh guarantees neither good nor bad results.

3. Acknowledges that the undersigned has been told if they feel tired, feel pain or feel out of the ordinary in any way either related to your training, or otherwise, that the undersigned should contact a physician at once.

4. Acknowledges that the undersigned will not hold EZ8 DC or any of its affiliates liable for injury, loss of work, or death.

5. Acknowledges that the undersigned assumes the risks of participating in fitness training, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Kathleen Pugh for the undersigned participating in said sporting events and/or training for said sporting events.

The Undersigned agrees that this is the full agreement between the parties, that Kathleen Pugh, nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.

__ I understand there is no refund policy.
__ I will remember to set my alarm and be at set location at designated time.
__ I will be dedicated to this program and give my very best.
__ I will have FUN!

____________________
Signature
____________________
Printed Name
____________________
Date