MultiSport Questionnaire

Name:

Street::

City:

State: Zip Code

Phone:

E-Mail:

How were you referred?:

PERSONAL DATA

Marital Status:

Height: Weight: Birthdate:

Occupation:

Brief Job Description:

Any Health Related Problems:

Average Hours Sleep Per Night:

GOALS

Goal Race For 2007:

Goal Race For LastYear and Result:

Other Races For 2007:

Races Completed in 2006:

Races Completed 2005:

Area That Needs Most Improvement:

ATHLETIC BACKGROUND

SWIMMING

In the last 12 months your best time for the following (fill in all that apply):

100 yards meters

400 yards meters

800 yards meters

1500 meters 1.2 miles 2.4 miles

How Often Do You Swim Per Week:

Do You Swim With A Master's Program:

Do You Own or Have Access to: Zoomer/Fins Pull Bouy Hand Paddles

CYCLING

In the last 12 months your best time for the following (fill in all that apply):

10 miles 40km 56 miles

112 miles other

How Often Per Week Do You Ride:

What is your longest ride in the past 6 months:

Do You Own A: Windtrainer Computrainer Power Meter

What Bikes Do You Own:

Do You Participate In Any Group Rides:

RUNNING

In the past 12 months your best time for the following (fill in all that apply):

5km 8km 10km Half Marathon Marathon

Your best run times in a triathlon in the past 12 months:

5km 10km Half Marathon Marathon

How often do you run per week:

Typical weekly mileage over the past 6 months:

Do you have access to a track nearby? yes no

What percentage of your running do you do on: roads trails track

What is your longest run in the past 6 months:

Do you participate in any group runs? ie. group long runs, group track workouts:

GENERAL TRAINING QUESTIONS

Do you own a Heart Rate Monitor: yes no

If so, make: model:

Do you own a computer interface for your Heart Rate Monitor: yes no

Have you done a bike or run Anaerobic Threshold test in the past 12 months: yes no

If so, what were the values: bike run

What are your best times for triathlons: Olympic Distance Half Ironman

Ironman

What is your typical time available to train each day (be as specific as possible):

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Please consult your physician before starting this or any exercise or training program.

WAIVER

I acknowledge that training for and/or participating in a triathlon, duathlon, cycling, swimming, running or any other endurance sporting event is an extreme test of my physical and mental limits and that such training and/or participation poses potential risks of serious bodily injury, death, or property damage. I have provided TriPower MultiSports with all information which in any way relates to or that could affect my physical health and attest that I am in good health and my physical condition has been verified by a licensed medical doctor.

Furthermore, in return for my participation in this program, I on behalf of myself and my heirs or executors I hereby:

a)WAIVE, RELEASE, and DISCHARGE TriPower MultiSports, their officers, directors, administrators, employees, consultants, coaches and agents from any claims, costs or liabilities for personal injury, illness, death or damages of any kind which I may have now, or at any time in the future, resulting from participation in this or any other program;

b) AGREE NOT TO SUE any of the persons or entities mentioned above for any claims, costs or liabilities that I have waived, released or discharged herein;

c) 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.

Submission of this form is agreement to the above terms.

Copy this form into an e-mail and send to tripower2000@msn.com