Client Questionnaire & Waiver

Client Questionnaire

* Indicates required field

Name of the Athlete *

First

Last

Primary Email Address *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Mobile Phone Number *

Home Phone Number *

What are the best times to reach you? *

Can I text you? *

Birthdate *

Age *

Height *

Weight *

Employer *

Job *

Hours/week *

How did you hear about these coaching services? *

Medical History Evaluation

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Relationship of Emergency Contact *

Primary Doctor *

First

Last

Doctor's Phone Number *

Please list any medications taken on a regular basis (prescription and non prescription)

Medication/Dose/Frequency/Reason *

List any medication you are allergic to (Medicine/Reaction) *

Please list any current illness, recent injuries, recent surgeries or past medical problems or surgeries of note. *

If female, is there any chance you could be pregnant? *

Yes No

Has a doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *

Yes No

Do you have chest pain brought on by physical activity? *

Yes No

Have you ever developed chest pain within the last month? *

Yes No

Do you tend to lose consciousness or fall over as a result of dizziness? *

Yes No

Do you have a bone or joint problem that could be aggravated by the proposed physcial activity? *

Yes No

Has a Doctor ever recommended medication for high blood pressure or a heart condition? *

Yes No

Are you aware, through your own experience or a doctor's advice, of any other physical reasons against your exercising without medical supervision? *

Yes No

Do you have any metabolic diseases, controlled or uncontrolled, such as diabetes, hyperthyroidism, hypothyroidism, etc? *

Yes No

Do you, or have you ever, smoked regularly? *

Yes No

Do you have high cholesterol? *

Yes No

Have you ever had an injury that caused you to stop exercising for more than one week? *

Yes No

Are you, or have you ever been, anorexic or bulimic? *

Yes No

Are there any other physical or emotional problems that may affect your training? *

Yes No

If there are any answers above that need further explanation, please do so here. *

What is your waking pulse? *

Is this high or low for you? *

Choose what you feel is your current fitness level compared to your highest fitness level in the past five years. (1 = high, 5 = low) *

Describe your current training week. If you keep a training log, include a copy of last week *

Is this MORE or LESS of a normal training week for you? *

Describe your longest single workout in the last three weeks: *

How many hours per week do you spend training now? *

Please list exactly when and how much time you have available for training? *

How many days per week do you take off from training? *

Ideally, how many days would you like to take off from training? *

What type of access do you have to gyms, classes, treadmills, pools, weights, etc.? *

Please list the equipment you have including, but not limited to, bike, heart rate monitor, power meter, swimming tools (paddles,fins, snorkel), GPS device, indoor trainer, etc. *

Do you know how to swim? *

Have you ever done a swim workout? *

List below all of the events you plan on possibly competing in this year. I understand this schedule is subject to change (in fact, I may suggest you change it). Please notify me if this schedule does change. For each priority level list the Date, Event, Distance and Your goal.

High Priority Events - these are the most important events of the racing season for you. There should only be a few of these because we will design your training schedule to taper and peak for them. *

Medium Priority Events - These events you want to do well but are not the focus of your season. We may rest for these events, but usually they will be thought of as race pace "workouts" to sharpen for the high-priority events. *

Low Priority Events - These are events of the least importance to you. They are the "fillers" to your season, and you will most likely compete for fun and to get a good workout. Do not include too many of these events, however, as they might detract from the focus. *

Athlete Waiver and Release

I acknowledge that training for and/or participating in a bicycle, running, swimming, triathlon or duathlon event is an extreme test of a person's physical and mental limits and such training or participation poses potential risks of serious bodily injury, death, or property damage. With full understanding of the risks I am taking, I HEREBY ASSUME ALL THE RISKS OF TRAINING FOR AND PARTICIPATING IN SUCH EVENTS and agree to the following (initial statement to which you agree at the "Init" space):

Mandi Kowal has been retained to assist me in the improvement of my fitness. (please initial) *

I hereby attest that I am in good health and my physical condition has been verified by a licensed medical doctor and, furthermore, the licensed medical doctor has been advised that I intend to participate in these events. (please initial) *

In consideration of being accepted as a fitness client by Mandi Kowal, Inc., I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns, or anyone else who might claim or sue on my behalf: (a) I WAIVE, RELEASE, AND DISCHARGE from any and all claims, costs, or liabilities for death, personal injury or damages of any kind, which arise out of or relate to my training for or participation in a bicycling, running, swimming, triathlon or duathlon event, THE FOLLOWING PERSONS OR ENTITIES: Mandi Kowal, Coach (b) I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims, costs or liabilities that I have waived, released or discharged herein; and (c) I INDEMNIFY, DEFEND, and HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions except those resulting from the willful acts or gross negligence of Mandi Kowal. (please initial) *

I am solely responsible for my debits. I agree to pay collection fees, including a reasonable attorney’s fee and costs of litigation, if my debits are 60 or more days overdue. (please initial) *

I agree to abide by the laws of the State of Iowa and to litigate any disputes between myself (the Client) and Mandi Kowal. within the legal jurisdiction of Iowa, Johnson County (please initial) *

I AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER, I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM WAIVING SIGNIFICANT LEGAL RIGHTS AND AM INCURRING SIGNIFICANT LEGAL LIABILITIES. I HAVE BEEN SPECIFICALLY ADVISED TO CONSULT WITH AN ATTORNEY IF I DO NOT UNDERSTAND ANY PORTION OF THIS RELEASE AND AGREEMENT. (please initial) *

Electronic Signature *

Date *

Submit