Run Strong Clinic Registration (Spring 2018)
Dates: Tuesdays at 7pm, Jan 9 - Apr 24

Location: Frontrunners Nanaimo (1825 Bowen Road)

Potential Goal Races: Eugene 1/2 & Full Marathon (Apr 28-29)*, Times Colonist 10k (Apr 29), Vancouver Marathon 1/2 & Full (May 6), Oak Bay 10k or Full Marathon (May 27), Run Like a Girl Be Fearless 11k, 1/2 and Full (June 2). Have another event in mind? No problem! Let Gillian know what you're awesome plans are and she will customize a Run Strong schedule just for you as part of your clinic fee!

*Did someone say SuperCrew Road Trip?! There will a reasonably large crew heading down to Eugene, Oregon together. If you are interested in this please let Gillian know in the registration form below. All registration, travel and accommodation bookings will be up to the individual, but I will be organizing the group so we coordinate and connect!

Before we can get started I have a few questions for you to finalize your registration. Thank you in advance for taking the time to complete this entire form.

If you have any questions never hesitate to email me at gillian@superyou.ca
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Contact Information
Name: *
Date of Birth (dd/mm/yy): *
Home Address: *
Preferred Phone Number: *
Email Address: *
Emergency Contact Name: *
Emergency Contact Phone: *
Payment information
Please note: payment is due in advance of clinic. If you prefer cash or cheque please contact Gillian at gillian@superyou.ca to arrange payment.
Method of Payment *
Please indicate your method of payment.
Goal Race (if applicable)
If you don't know right now, hey, no worries. But if you do, tell me what your big awesome plans are!
Spring 2018 Goal Race(s)
Clinic Shirt
As part of your registration you receive a super cool Super You clinic shirt. Please specify your sizing below!
T-Shirt Size
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Running History
Tell me a little more about your running experience!
Tell me about your running experience
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Tell me about your running goals:
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Tell me about your pace (choose the closest option):
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Medical History Questions:
Please be honest when answering these questions.  
Medical Conditions *
Please check if you have experienced any of the following:
Required
If you checked yes to any of the above medical conditions please elaborate below
Please inform me if you have been approved by your physician for exercising.
PAR-Q
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. Check YES or NO.

IMPORTANT: please be advised that if you check YES to the below questions I am required to obtain a note from your doctor approving you for exercise prior to the start of clinic.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
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? *
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Do you know of any other reason why you should not do physical activity? *
Did you answer YES to any of the questions above? *
Informed Consent
I understand the potential risks involved in participating in a rigorous physical exercise program. I assume the responsibility and risks as explained to me. I understand that participating in an exercise program may include, but not be limited to, serious bodily injury, heart attack, stroke, or even death. I consent voluntarily to participate in an exercise program based on the information provided to me.
I agree to the above informed consent. *
Liability Waiver
I certify and acknowledge:

That Gillian Goerzen/ Super You Fitness & Nutrition Coaching ("Super You") has advised me prior to my commencement of participation in cardiovascular and resistance training programs that such participation could result in physical injury.

That I freely and knowingly assume the risk in such programs, and I hereby waive any right, claim, or cause of action against Gillian Goerzen or Super You and release her and/or her company from any liability for any injury, cost, damage, expense or claim, which I or anyone on my behalf might incur as a direct or indirect result of my participation in this cardiovascular and resistance-training program.

That I have read this Liability Waiver form, understand and agree with each of the foregoing points, and have received a copy a copy of this release form on this date.
I agree to the above Liability Waiver. *
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