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Running History and Coaching Interest Form

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

DECLARATIONS:

This Agreement is entered into between Excel Rocktown and the undersigned (“Client”). The provision of coaching services by Excel Rocktown to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK:

You agree that if you engage in any physical exercise or activity, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Excel Rocktown or otherwise, including injuries or damages arising out of the negligence of Excel Rocktown, whether active or passive, or any of Excel Rocktown’s affiliates, employees, agents, representatives, successors, and assigns.

Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), sports fields, roads/trails (public or private), courts, or other areas, locker rooms, sidewalks, open bodies of water, swimming pools, swim flumes, parking lots, stairs, whirlpools, saunas, steam rooms, or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, running (indoor or outdoor), cycling (indoor or outdoor), swimming (indoor or outdoor) or cross training activities. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Excel Rocktown or otherwise.

RELEASE:

You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Excel Rocktown (and Coach’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Coach, whether active or passive, or any of Excel Rocktown’s affiliates, employees, agents, representatives, successors, and assigns.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including coaching, (d) traveling to or from coaching session(s).

INDEMNIFICATION:

By execution of this agreement, you hereby agree to indemnify and hold harmless Excel Rocktown from any loss, liability, damage, or cost Excel Rocktown may incur due to the provision of coaching by Excel Rocktown to you.

ACKNOWLEDGMENTS:

You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance of the waiver will continue in full legal force and effect. You acknowledge that Excel Rocktown offers a service to their clients encompassing the entire recreational, sporting and/or fitness spectrum. This release is not intended as an attempted release of claims of gross negligence or intentional acts.

You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against Excel Rocktown for coach’s negligence, or for any defective product used while receiving coaching services from Excel Rocktown. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

Name*

E-mail*

Phone Number*

Gender*

Age*

Height (Ft/In)*

Weight (lbs)*

How did you hear about Excel Rocktown?*

Preferred Coach for your Consult*

Preferred Package*

List any major health or training complications you have had in the past.*

Give details of specific workouts you have performed over the past 6 weeks and any race performances from the past 6 months. (provide times and distances)*

How much free time do you have, on a daily average, for running? (Hrs/day)*

How many days per week are you able to and/or would like to train?*

What type of physical activities do you currently participate in?*

What competitive sports (if any) have you participated in?*

Why, when, and how did you get started running?*

Will you be training by yourself or others?*

What are your short and long-term running goals?*

When do you have the most energy: morning, midday, evening?*

Does your schedule vary, or is it fairly consistent?*

What days/times do you have to train?*

How important is structure in your life?*

What aspect of running are you most intimidated by (if any)?*

What are your top three running-related strengths and weaknesses?*

Do you respond better to tough love, handholding, or somewhere in between?*

Do you crack, stay the same, or thrive under pressure?*

What are you better at? Short, hard sprints or long, endurance efforts?*

How competitive of a person are you? Rate yourself 1-10 (10= the most)*

How much do you enjoy the intensity of pushing hard while training/racing (1-10)?*

How confident are you in your abilities as a runner (1-10)?*

Do you like to be challenged? 1-10 (1=true, 10=very true)*

Are you susceptible to mental burnout as a result of training? 1-10 (1=untrue, 10 very true)*

What is your current weekly training volume (distance and/ortime) and how long have you been running consistently?*

Questions that you have for me.*

Read the waiver above and provide your e-signature as your agreement to the waiver terms.*