Personal Information

First Name (Field to be completed)

Last Name (Field to be completed)

Your Email

Age

Sex MaleFemale

Address

Street Adress
Street Address Line 2
City
Postal Code
Country

Phone

Running Profile

Current weekly mileage (kms)
Longest run of the week (kms)
Number of days you run each week

Briefly describe a typical training week for yourself
How long have you been running?
General medical condition
Are you involved in any other forms of training other than running? If so, can you please advise what that may be and where it fits into your current week

Running Times

5km personal best time
5km most recent time
10km personal best time
10km most recent time
Half marathon personal best time
Half marathon most recent time
Marathon personal best time
Marathon most recent time

Running Goals

Briefly outline your personal goals over the next 12 months
Any other comments you would like to make
How did you hear about my online coaching program?

Payment

PaypalEFTChequeGift Voucher

If paying by EFT

I have/will deposit one of the following amounts via internet banking:


$75 = 4 Week program

$105 = 8 Week program

$155 = 12 Week program

$200 = 16 week program

$250 = 20 week program

$300 = 24 Week program

$380 = 30 week program

$600 = 12 month program

Or amount quoted by Pat

Account Details:

Bank: Westpac
Account name: Pat Carroll
Account number: 193331
BSB: 034037
Reference: Surname

Waiver and Release

I acknowledge that a training program set by Pat Carroll involves strenuous cardiovascular activity and it is my sole responsibility to ensure my physical condition is not at risk by participating in such a strenuous activity.

It is necessary to have a physical exam by a physician before beginning any strenuous exercise program.

I understand the risks involved in running, walking or other fitness activities and assume personal responsibility for my health and safety while participating in this program.

I’m in proper physical condition to undertake a running program. I release Pat Carroll from any and all claims or damages arising from my participation in an individualised training program.

I also understand and accept the following responsibilities:

Pat Carroll’s Responsibilities:

• To design an individualized training program taking into consideration the runners current fitness level and future goals.
• To be continually available via email to offer advice on any running related matters.
• To reply to emails within 24 hrs (except during public holidays) and to ensure any basic questions sent via email relating to nutrition are answered with 48hrs.

Runners Responsibilities:

• To advise Pat Carroll your progress via email. This being your results from training sessions and racing whenever applicable.
• Notify Pat Carroll when you may be in the early stages of an injury or illness so the appropriate adjustments can be made to your program.

Injury and Medical advice:
Pat Carroll is not qualified to offer advice on such matters although basic information “may” be provided.

Injury:
Ideally you’ll seek treatment from either a sports physiotherapist/a podiatrist or a massage therapist. A sports doctor will be of benefit if you have a severe injury.

Medical:
Ideally you’ll be consulting a medical practitioner for any health related issues.

I accept the terms outlined above?

First Name

Last Name