Please print and fill out the form below and mail it with your payment (or if
you register online, please bring this form with you to the first day of camp). The waiver must be signed.
Confirmations and detailed instructions will be emailed prior to the start of the EZ8 camp.
You have two payment options (all payments and registration forms must be received no later
than the first day of camp):
1) You can mail your payment to Stephane Doyle, 381 Creekstone
Court, Longwood, FL 32779 along with you name, email address and phone number. Please email
me at stephruns@cfl.rr.com to let me know you have mailed your payment so I can reserve your spot. Please make checks
payable to Stephanie Doyle. The fee is $260 for the 8-week camp. Former EZ8 members, as well as Train with Steph
clients and TRI it now members receive a 20 percent discount ($208) but I still need your form!
2) Online registration is available at active.com! (the active.com fee is paid for by OrlandoEZ8).
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 heard about EZ8 from ______________________________.
My main goal is to ____________________________________________________________________.
I am signing up for the camp in _________________ beginning ___________________________________.
If you are a returning EZ8 Runner, you may skip this next section if there
are no changes.
MEDICAL HISTORY
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 Stephanie Doyle/Orlando EZ8, its
officers, affiliates, and executors.
The undersigned hereby acknowledge
that the following was explained to me and/or agree to the following:
1. Acknowledges that Stephanie Doyle 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 Stephanie Doyle will provide fitness instruction and coaching to the undersigned, but that Stephanie
Doyle 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 Stephanie Doyle, Orlando EZ8,
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 Stephane Doyle 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 Stephanie Doyle, 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
