Participants Full Name: *

Participants Address: *

Participants D.O.B: *

Sex: MaleFemale

Weight - KG: *

Height - CM: *

Email: *

Company: *

Phone: *

Membership: Option 1 10 pack ($60)Option 2 10 pack ($108)5 KMOption 2 10 pack ($108)12 KMOption 3 10 pack ($124)21 KM

Female T Shirt Size: -81012141618

Male T Shirt Size: -SMLXL2XL3XL

Payment Type?: Credit card over phoneCredit card on the night'Electronic Fund Transfer'Electronic Fund TransferCash

Training and racing experience?: *

Strengths/weaknesses?: *

Primary training goal?: *

Events for year?: *

Do you use weights?: *

Family medical issues?: Include who,what and when

Asthma?: *

Diabetes?: *

Low Blood Pressure?: *

High Pressure?: *

High Cholesterol?: *

Heart Problems?: *

Epilepsy?: *

Dizziness?: *

Chest pain?: *

Arthritis?: *

Osteoporosis?: *

Joints, past/present?: *

Other illness?: *

Take any medication?: *

Last Doctors visit?: *

How often do you go?: *

Reason for going?: *

Are you pregnant?: YesNo*

Last child D.O.B?:

Exercises you enjoy? : *

Exercises you dislike?: *

Current activity levels: 0 Avoid walking or exertion, e.g.drive instead of walking.1 Walk for pleasure, rarely heavy breathing or perspiration2 Golf, weight lifting, yard work, 10-60 min/week3 Golf, weight lifting, yard work, 1hr+ a week4 Ride or run, ie <30 min/week in similar activity.5 Ride or run, ie 30-60 min/week in similar activity.6 Ride or run, ie 1-3 hr/week in similar activity.7 Ride or run, ie 3+ hr/week in similar activity.7.5 Municipal Level.8 Regional/State Level.8.5 National Level.9 National Chamionship Level.9.5 World Class Level.10 World Champion.

Next of kin Name: *

Next of kin contact Number: *

All information is correct?: *

Todays Date?: *