Occupation: Brief Job Description:
Any Health Related Problems?

Average hours of sleep per night:

Goals

2007 Goal Race (only one!)
Other 2007 Races:

2006 Races:

Athletic Background

Swimming:

When did you start swimming?
Where do you swim?
Distance to pool from home or work:
How often do you swim?
How many yards/meters do you swim each week?
Do you belong to a Master's swim program? yes no

Best 800 time:(indicate meters or yards)
Best 1500 time:(indicate meters or yards)
Best 2.4 mile time:
Do you have access to:
Pull bouy: Paddles: Kickboard: Zoomers/Fins:

Cycling:

When did you start cycling?
Where do you ride?
Brief description of available cycling routes (distance, terrain, distance from home):

How often do you ride?
How far do you ride each week?
Do you own a windtrainer/computrainer?
Does your bike computer have a cadence feature? yes no
Do you belong to a cycling club?
What bike(s) do you own?
Best 40km/25mile time: Best other times:

Running:

When did you start running?
Where do you run?
Do you belong to a running club?
How often do you run?
How far do you run each week?
Brief description of available running routes(distance, terrain, distance from home):

Best 5km time: Best 10km time:
Half-marathon time: Marathon time:

General Training

Do you own a heart rate monitor? yes no
Do you own a computer interface for your monitor? yes no

Have you had a recent A.T. test done?
Cycling results: Running results:
What is your best Olympic Distance time?
What is your best half Ironman time?
What is your best Ironman time?

What is your typical available time to train per day:

Do you have specific group training that you attend? If yes, what day/time and in what sport.

Any additional comments you would like to add?

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 Mike Plumb 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 Mike Plumb, his 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.

Please copy and paste this form into a MS Word document, or directly into an email and send to: tripower2000@msn.com