GEAR SHOP


ONLINE TRAINING PROGRAM ENTRY FORM AND HEALTH HISTORY QUESTIONNAIRE
 
 Personal Information:
SELECT A TRAINING PROGRAM:   
 
* First Name
* Last Name
Phone (Work)
* Phone (Home)
Age
E-mail Address
Address
Emergency Contact
Phone Number
   
 Shipping Information:

* Name :

* Company :

* Address :

* City:

* State:

* Country :

* Zip Code :

* Phone :
  Billing Address : ( **If the same as shipping address, check here )
 Billing Information:

Name :

Company :

Address :

City :

State :

Country :

Zip Code :

Phone :
 Credit Card Information:

Card Type :

Card Number :

Expiration Month :

Expiration Year :

Initials
List any medications you currently take

List any injuries or hospitalizations you've had in the last five years

Please check if you have ever been diagnosed with one of the following

Heart Disease
Heart Arrhythmia
Asthma
High Blood Pressure
Hypoglycemia
Stroke
Diabetes

Do you smoke?

 

Yes
 

No

Do you have any allergies?   If yes, please list them

How many years have you been competing in multisport?

RELEASE OF LIABILITY, HOLD HARMLESS AND INDEMNITY:
The undersigned is participating in athletic training and coaching programs that involve strenuous physical activities with the potential for bodily injury. The activities include the use of equipment that is also potentially dangerous and that can also cause injury. The risks of participation in the activities and use of equipment include, but are not limited to, risks of serious bodily injury and/or death. By signing below you acknowledge that you are fully aware of and accept the risks of injury and/or death. The undersigned further hereby releases Lee Zohlman, Erinne Zohlman, BodyZen Multi Sport Coaching, and BodyZen Enterprises Inc. their agents, employees, contractors, and individuals or entities acting on their behalf (hereafter RELEASEES) from any and all liability including, but not limited to, liability for bodily injury, medical expenses, and/or death arising from participation in the athletic training and coaching programs. The release of liability EXPRESSLY INCLUDES A RELEASE OF ANY AND ALL LIABILITY FOR THE NEGLIGENCE AND/OR NEGLIGENT ACTS OF RELEASEES, in the athletic training and coaching programs.

The undersigned agrees to indemnify and hold harmless Releasees from any and all liability, expenses, costs and/or losses arising out of participation in the athletic training and coaching programs, activities and/or use of equipment. The undersigned further agrees to indemnify and reimburse Releasees for any and all damage the undersigned causes to Releasees’ equipment during the undersigned’s participation in the athletic training and coaching programs.

Signed and acknowledged , 2009.
   
Name of participant Initials
   
Name of participant Initials