Program Sign up Form

To sign up for a coaching or training program please fill out and submit this form.

This will allow us to get an idea of your training background and details of your training goals, please fill out the sign up questionnaire below. This includes personal info, training background, and a brief medical questionnaire. The more information you can provide on your current training the better, as it is this information that will use to construct your initial training program.

If you wish to attach additional information please email it through to bwisbey@endurancetraining.com.au after submitting this form.

We will contact you shortly after submitting this form.

Personal and Athletic Information
Program Type Coaching ($495 per 3 months) Training Program ($55 per month)
Given Name	Family Name
Postal Address	Suburb
State	Post Code
Date Of Birth	Gender Male Female
Preferred Phone Contact	Weight (kg)
Height (cm)	Occupation
Email

Training and Competition Information
Sport	Years Training
Longest Session In The Last Month	How Many Times Per Week Do You Usually Train? Less Than 4 Less Than 6 Less Than 8 More Than 8
Training Background
Hours available for training per week	What Day Is Best Suite For You To Have Off? Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Preferred Training Times Each Week (Day & Time)
Current Training Details
Goals (Competition or Otherwise)
Injury History
Any Other Background Information

Medical Conditions
Do You Have Diabetes? Please Select.. Yes No	Have You Ever Had A Stroke? Please Select.. Yes No
Has Your Doctor Ever Said You Have Heart Trouble? Please Select.. Yes No	Do You Take Asthma Medication? Please Select.. Yes No
Are You, Or Do You Have Reason To Believe, You Are Pregnant? Please Select.. Yes No	Is There Any Other Physical Reason That Prevents You From Undertaking An Exercise Program (eg. cancer, osteoporosis, severe arthritis, mental illness, kidney or liver disease? Please Select.. Yes No
Do You Take Any Regular Forms Of Medication? Please Select.. Yes No	If So, What?

Signs and Symptoms
Do you often have pains in your heart, chest or surrounding areas, especially during exercise? Please Select.. Yes No	Do you often have pains in your heart, chest or surrounding areas, especially during exercise? Please Select.. Yes No
Do you experience unusual fatigue or shortness of breath that comes on after stopping exercise? Please Select.. Yes No	Have you been awakened at night by an attack of shortness of breath? Please Select.. Yes No
Do you experience swelling or accumulation of fluid in your ankles? Please Select.. Yes No	Do you often get the feeling your heart is skipping beats at rest of during exercise? Please Select.. Yes No
Do you regularly get pains in your calves and lower legs during exercise which are not due to soreness or stiffness? Please Select.. Yes No	Has your doctor ever told you that you have a heart murmur? Please Select.. Yes No

Cardiac Risk Factors
Do you smoke cigarettes daily? Please Select.. Yes No	Has your doctor ever told you that you have high blood pressure? Please Select.. Yes No
Females: Have You Experienced Menopause Before The Age Of 45? Please Select.. Yes No	What is your blood pressure, if known (eg. 120/80)?
Has your father, mother, brother or sister had a heart attack or suffered from cardiovascular disease before the age of 65? Please Select.. Yes No

Statement by Participant

I completed the above questionnaire and I acknowledge that Endurance Sports Training has not and is not able to provide me with medical advice. I agree that I am participating in the exercise sessions at my own risk and that I will not hold Endurance Sports Training responsible for, and I will not bring any claim or action against Endurance Sports Training in relation to any loss, claim, damages, expenses, illness or injury arising out of or in connection with my participation in the exercise sessions. I warrant that I am in a fit state to participate in the exercise sessions and that if I answered YES to one or more of the above questions, I have checked with my doctor before participating in the exercise sessions.

Please type your name here to indicate you have read and agree with this statement

Date

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