Background Information

Please fill out the form below and someone will contact you within 24 hours. Try to be as accurate and complete as possible when filling out this form. The information you supply allows me to tailor your training to your specific, personal needs. If you feel uncomfortable providing this information online, please let me know.
* First Name
 * Last Name

* What level of training are you interested in:
Level III - $450/mo with Coach Mike
Customized Training Plan - with Coach Mike
Level III - $395/mo with Coach AJ
Level III - $395/mo with Coach Curt
Customized Training Plan - with Coach AJ
Level III - $395/mo with Coach Amy
Level II - $235/mo with Coach Amy
Customized Training Plan - with Coach Amy
Level I - $150/mo with Coach Mark - Full for 2008
Level II - $235/mo with Coach Mark - Full for 2008
Level I - $150/mo with Coach Amanda
Level II - $235/mo with Coach Amanda
Level III - $375/mo with Coach Ali
Level II - $275/mo with Coach Ali
Level II - $235/mo with Coach John

Address

* Number & Street
      
Suite
      
* City
 * State
 * Zip
 * Country
Phone
* Home Work Cell

* E-mail

You can contact me by (check all that apply):
Home Phone Work Phone Cell E-mail

* Gender
M F 		* Date of Birth mm/dd/yyyy
 / / 		* Height
' "		 * Weight
lbs.

* Occupation:

Travel for work:

Marital Status/ Significant other:

Children:

Other criteria that may affect training or training time:

* How did you hear of D3 Multisport?

 

*Medical History (Note: All medical questions must be completed)

Y N * Have you ever experienced chest, shoulder, neck or arm pain after exercise?
Explain
Y N * Have you ever felt lightheaded, dizzy or fainted after exercise?
Explain

* Have you been diagnosed with any of the following conditions? (Check all that apply)
Asthma
 Diabetes
Heart Trouble
High Blood Pressure
Explain

Y N * Do you have any medical conditions that would be adversely affected by exercise?
Explain
Y N * Do you have any injuries, past or present, that would be adversely affected by exercise?
Explain
Y N * Are you currently using any medications?
Explain
Y N * Does your doctor recommend that you DO NOT exert yourself or perform strenuous exercise FOR ANY REASON?
* When was your last physical examination? / /

 

Waiver

I acknowledge that training for and/or participating in a swimming, bicycle, running triathlon or duathlon event is an extreme test of my physical limits and such training and/or participation poses potential risks of serious bodily injury, death, or property damage. I HEREBY ASSUME, WITH FULL UNDERSTANDING, ALL RISKS OF TRAINING FOR AND PARTICIPATING IN SUCH EVENTS and attest to the following:
I am in good health and my physical condition has been verified by a licensed medical doctor.

I WAIVE, RELEASE AND DISCHARGE Michael Ricci, D3, its employees, coaches, consultants and any agents for the above (collectively,"D3") from any and all claims, costs, or liabilities for personal injury, death, or damages of any kind arising out of or related to my training for or participation in a swimming, bicycle, running triathlon or duathlon event.

I AGREE NOT TO SUE any of the persons or entities mentioned above for any claims, costs or liabilities that I have waived, released or discharged herein.

I INDEMNIFY, DEFEND AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions except those resulting from the will full acts or gross negligence of D3

I AM EIGHTEEN (18) YEARS OF AGE OR OLDER.
I AM UNDER EIGHTEEN (18) BUT HAVE PARENTAL CONSENT.
I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS.
* Name

* Date
/ /
Yes No
Selecting "Yes" acknowledges and affirms your agreement to the statements contained within this waiver and that the information you have provided is true and accurate to the best of your knowledge.
* Please re-confirm your email address

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