Registration and Release Form - EZ8 Running
Snoqualmie, Washington's Best Women's Running Group
REGISTER SECURE ONLINE HERE >>>

Or PRINT this now and send it in by fax or mail.

Running Group Registering for ______________

EVENT START DATE ___________ REGISTRATION FEE $ __________

CALL 425-890-5037 with any questions.
Please make check payable to: EZ8 Running

Please mail to:
EZ8 Running
c/o Kimbrough Kendall
P.O. Box 1793
Snoqualmie, WA 98065
You may fax to: (425) 890-5037

All payments must be received by the first day of the program.Name:______________________________________ Date: _______

Street:___________________________________________________________________________

City:_______________________________________ State:______________Zip:_______________

Profession: _________________________________

Date of Birth ___/___/___

Emergency Contact and phone number______________________________________________________

Home Phone (_____)____________________ Work Phone (_____)_____________________

Fax Number (___)_______________________

E-mail ___________________________@__________________________

I can run a _____ minute/mile.

I rate my current fitness level as a _____ (1-10), ten being high.

I was referred by ______________________________.

My main goal is to ____________________________________________________________________.

Account Number:__________________________________ Expiration Date:______/______ CVC Code*:______

Name on Card: ________________________________ Signature: ____________________________
*Visa and Mastercard - In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a special 3 digit code. This 3 digit code is your CVC. American Express - On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code. If paying by check, please make payable to EZ8 Running.Confirmations and detailed instructions will be mailed prior to the start of The “Easy Eight” Running Program. Waiver must be signed prior to participation. I will be signing up for the “Easy Eight” Running Program beginning on _____________, 20__. This program is three days a week for 8 weeks.

MEDICAL HISTORY
If you are a returning EZ8 Runner, you may skip this next section if there are no changes.

What is the date of your last physical exam?

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

3. Do you have a seizure disorder (epilepsy)? Yes No

4. Do you have diabetes Adult or Juvenile? Yes No
List Medications: ______________________________

5. Have you ever been found to be anemic (low blood count)? Yes No

6. Do you have High Blood Pressure (hypertension)? Yes No
List Medications:

7. 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

8. Do you have asthma? Yes No
List Medications:

9. Have you ever had a severe neck injury?
Describe:



10. Have you ever been knocked unconscious?
Describe:



11. Do you wear glasses or contact lenses? Yes No

12. Have you had a broken bone or fracture in the past 2 years?
Describe:


13. Have you ever injured your back?
Describe:


14. Do you have back pain?
Never Seldom Occasionally Frequently with vigorous exercise or heavy lifting

15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
Describe:



16. Do you have other physical conditions, which cause pain?
Describe:



17. Detail any surgical procedures:



18. What are your goals for the next three months?



19. Have you had your body fat tested?
If yes, what percent is it?


20. Are you training for a specific event?
If yes, explain:


21. What do you think your timed mile will be?

22. 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 EZ8 Running, its officers, affiliates, and executors. The City of Snoqualmie, Washington. The purpose of EZ8 Running is to provide fitness instruction and coaching for various levels of athletes/individuals.The undersigned hereby acknowledge that the following was explained to me and/or agree to the following
:
1. Acknowledges that Kimbrough Kendall 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 Kimbrough Kendall will provide fitness instruction and coaching to the undersigned, but that Kimbrough Kendall does not guarantee 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. Acknowledge that the undersigned will not hold Adventure Boot Camp, EZ8 Runners, or any of its affiliates liable for injury, loss or 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 Kimbrough Kendall 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 Kimbrough Kendall, 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