USA Triathlon Certified Training Center
Registration Form

Athlete's Name Date:
Birth Date
Address Gender
Home Phone
Cell Phone
E-mail
How did you hear about us? If referred, by whom?
Legal Guardian's Name Relation to Athlete
Address Home Telephone
Work Telephone
E-mail Cell Phone
Legal Guardian's Name Relation to Athlete
Address Home Telephone
Work Telephone
E-mail Cell Phone
Emergency Contact Name Relation to Athlete
Home Telephone Cell Phone
Medical Insurance Physician
Telephone
School
Sport Played Coach
Coach's e-mail Telephone
Sport Played Coach
Coach's e-mail Telephone
Select/Club team Coach
Coach's e-mail Telephone
Team Web site

Waiver and Consent

By checking this box, I certify the following:

I know that weight training and cardiovascular exercise are potentially hazardous activities. I should not enter unless I am medically able, and take into account any preexisting medical conditions, and in consultation with my physician. I assume any and all risks associated with this activity. Having read this waiver and knowing these facts, and in consideration of your providing training services for me, I for myself and anyone entitled to act on my behalf, waive and release USA Triathlon Regional Training Center at Great River Medical Center, its employees and all others connected with this facility. They are not held liable or responsible for any injuries I may suffer while training or as a result thereof. In this connection, I hereby waive any claim for damages to myself or my property. I grant full permission for use of photographs, videotape or motion pictures of me, and/or quotations from me in legitimate accounts and promotions of this facility.

Training center staff will contact you within 48 hours of receiving this registration form to schedule appointment times and services.

Medical History Questionnaire

1. Do you have a history of any of the following medical conditions?
Heart murmur Heart disease Heat illness Diabetes
Mononucleosis Concussions Ulcer Frequent indigestion
Convulsions Epilepsy Hernia Asthma
Seizures Arthritis Chronic headaches Shortness of breath
Dizziness Varicose veins Cancer Irregular heartbeat
Back/Neck problems Allergies; to what? Other
2. Do you take medications regularly? YesNo
If so, please describe:
3. Have you ever had surgery? YesNo
If yes, please describe:
4. Have you had organs removed? YesNo
If yes, which:
5. Have you ever fractured any bones? YesNo
If yes, list them:
6. Do you have any plates, pins, or screws implanted in your body? YesNo
If yes, describe:
7. Please select any injuries that have disabled you for more than seven days, and provide a brief explanation.
Head Nose or jaw Elbow, wrist or hand Neck
Shoulder Back Chest or abdomen Knee(s)
Thigh Hip or pelvis Lower leg Ankle or foot
8. Have you ever been advised to have surgery to correct an injury, but decided against it? YesNo
If yes, explain:
9. Would you describe yourself as:
A nervous person Accident prone Tight muscled Very flexible
Sensitive to pain Underweight Prone to colds Overweight
10. Do you wear contact lenses and/or glasses? YesNo
11. Do you wear a dental plate, bridge or false teeth? YesNo
12. When was your last tetanus booster shot given?
13. Do you ever cough, wheeze or feel short of breath during exercize or in cold weather? YesNo
14. Are you presently under a physician's care for any ailment or injury? YesNo
If yes, describe:
15. Do you know of any health reason why you should be limited from participating in physical activity? YesNo
If yes, describe:
16. When was your last physician's visit and last physical?

Training History

How many days each week do you train and/or compete?
How many minutes does each session last, on average? Minutes
What sports are you training for?
Are you in your Offseason Preseason Competition season Active season
How many years have you been training for this sport? Years
How many years have you competed in this sport? Years
What other sports do you train for and/or compet in?
How long have you been training and competing in this sport? Years
What other sports have you participated in for more than two or three years?
What types of excercise/training do you participate in?
Walking Jogging/Running Treadmill running Trail running
Track workouts Stationary bike Road bike Swimming
Stair climber Elliptical trainer Rowing machine Free weights
Plyometrics Weight training Pool exercises Cross training
Aerobics classes Dynamic stretching Yoga/Pilates

By checking this box, I certify the following:

I have reviewed and answered each question to the best of my knowledge.  I authorize the release of this information to my primary physician(s) if necessary.  Information will not be released without my written consent, but the questionnaire information may be used for statistical and/or scientific studies with my right of privacy retained.