Get into Running Health Check – Lee Merrien Running

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Get into Running Health Checkinfo@annibisson.com2023-12-19T08:33:34+00:00

Get Into Running

Lee Merrien Running Health Questionnaire

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Name *

First

Last

Email *

Phone or mobile number *

Address

Parish

Postcode

Date of Birth

T-Shirt Size

Please tick if any of the following have currently, or have you ever affected you..

High or low blood pressure, Dizziness or fainting
Chest pains, heart trouble or stroke
Epilepsy
Diabetes
Asthma or other respiratory problems
Any Allergies (please list below)
Any Surgery (please specify below)
Any bone, joint or msucular problem or athritis
Any long standing or sustained injuries or illnesses we should be aware of (please specify below)

Please provide details if any of the conditions above applied to you or if there are any other medical information or condition we should be made aware of…

Are you currently pregnant or have you given birth in the last 6 months

Yes
No
N/A

Emergency Contact Name *

First

Last

Emergency contact mobile or telephone number

Permission for promotional material *

I understand that Lee Merrien Running will at times, capture and use photographic and video footage during the sessions which may be used for promotional material. I consent to any footage captured in sessions to be shared via social media or on their website but understand that I have the right to opt out of being included in such material by request. In submitting this form I confirm that I have read its contents in its entirety and that my answers to the health questions above are true and accurate.

I am fit & able *

I believe that I am fit & able to participate safely in any exercises and activity during the session. Should however any of my medical information change after submitting this form, I will inform Lee Merrien Running before undertaking any further exercise. I understand that I am responsible for my health and monitoring myself throughout the training and should any unusual symptoms occur, I will cease participation and make my coach aware immediately. Finally I have answered all of the previous questions accurately and honestly, and I acknowledge that Lee Merrien Running nor their coaches are neither liable nor any other person for any claims or causes of action whatsoever arising out of or connected with services provided.

Discharge *

I hereby discharge any Lee Merrien Running coach, trainer or employee from any such claim or actions.

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lee@leemerrienrunning.com