CREATING MOMENTUM COACHING
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    ​Initial Coaching Assessment and Waiver of Liability 





    Running and Fitness History
    ​

    Up to 6 Personal Best Time will be sufficient. Include a variety of events such as 1 Mile, 5k, 10k, half marathon, marathon and any ultras you have raced.



    Training Preferences:

    Running Shoes: (indicate if you wear a shoes for special purposes, e.g. Road Training, Trails, For Racing, Due to Injury) Manufacturer:__________________________ Model:____________________ Purpose: ____________ Date Purchased:________ Manufacturer:__________________________ Model:____________________ Purpose: ____________ Date Purchased:________ Have you had a Gait analysis? Yes No When? ___________ Where? _________________ Outcome: ___________________


    Do you see a Podiatrist? Yes No Do you use a GPS Watch? Yes No Do you Log your miles? Yes No
    If you wear orthotics, what issue do they correct? ___________________________________ Which Watch? _____________ Do you use an App to track mileage? _________________
    Do you own a Treadmill: Are you a member of a Gym? Yes No INJURY HISTORY: List any relevant injuries? (Please attach additional page if necessary) 


    ​


    Sports Injury History


    PLEASENOTE: THECOACHINGGUIDANCEPROVIDEDBYSHANNONMCGINNANDCREATINGMOMENTUMISNOTINTENDEDTOSUBSTITUTEPROFESSIONAL MEDICAL ADVICE. ALWAYS SEEK THE GUIDANCE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTHCARE PROVIDERS FOR ANY QUESTIONS YOU HAVE REGARDING A MEDICAL CONDITION. NEITHER THE CONTENT NOR ANY OTHER SERVICE OFFERED THROUGH THIS PROGRAM IS INTENDED TO BE RELIED ON FOR MEDICAL DIAGNOSIS OR TREATMENT. NEVER DISREGARD MEDICAL ADVICE OR DELAY IN SEEKING IT FOR ANY REASON. 

    ​

    RECENT TRAINING: Describe your most recent 4 weeks of training. List the Miles or Time spent running, your Pace, the surface or terrain (road, track, hills, trails, treadmill, etc) and any additional cross-training (weights, yoga, cycling, swimming, etc). 


    ​
    ​Four
    Weeks
    ​Ago

    Three 
    Weeks
    ​Ago

    2 weeks ago

    Last Week
    ​

    Available Training Time
    ​

    Lifestyle

    ATTESTATION OF GOOD HEALTH



    Waiver......


    Waiver of Liability, Assumption of Risk, and Indemnity Agreement
    Waiver: In consideration of being permitted to participate in training provided by Shannon McGinn Creating Momentum, LLC, I, for myself, my heirs, personal representatives and assigns, do hereby release, waive, covenant not to sue and discharge Shannon McGinn Creating Momentum, LLC or Shannon McGinn individually from liability from any and all claims including the negligence of Creating Momentum and/or Shannon McGinn resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in a running and/or walking training program.
    __________ (Initial*)
    Assumption of Risks: Participation in physical activity and conditioning programs carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I know that exercise is a potentially hazardous activity and I certify that I am in good health and physically fit to enter into a general conditioning program. I acknowledge that I am aware of the many risks involved in exercise in general and in long distance running specifically, including but not limited to: 1) minor injuries such as scrapes, bruises, sprains and strains, 2) more serious injuries such as joint, muscle, and bone injuries, concussions and other head injuries, 3) heat- related injuries such as heat stroke and heat exhaustion, dehydration and over-hydration conditions such as hyponatremia, and 4) catastrophic injuries and conditions such as heart attacks and other conditions or injuries which could be fatal. I have read the previous paragraph and I know, understand, and appreciate these and other risks that are inherent in exercising and training for general conditioning, for health improvement, and for improved physical performance. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
    __________ (Initial*)
    Indemnification and Hold Harmless: I, for myself, my heirs, personal representatives and assigns, also agree to INDEMNIFY AND HOLD HARMLESS Shannon McGinn Creating Momentum, LLC and Shannon McGinn from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in Shannon McGinn Creating Momentum,LLC and Shannon McGinn’s Training Program.
    __________ (Initial*)
    Severability: I, for myself, my heirs, personal representatives and assigns, further expressly agree that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of New Jersey and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
    __________ (Initial*)
    Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
    ____
    / Your Typed Name* / Date
    *When initialing or signing electronically, pleasure use the /s/ signature method to indicate that it is your intent for your typed initials or your typed name to be


    Print Name: ____________________________________________
    Signature*: ____________________________________________ ____________________________


    *You may Opt Out of Electronically signing this document by printing, hand signing, and returning as an emailed attachment or by regular mail.
    considered equal to your handwritten signature. (i.e. /Shannon McGinn/ or /SM/. Please note that the slash marks are required.) Electronically-signed documents aTnods/oigrneelelecctrtoronniciccaollyp,iepsleoafsheatnydp-esyigonuerdnadmoceutmoeindtsic,ainteclyuoduinhgabvuetrneoatdliamllitedrmtos ascnadncnoendiatitotancshamnednintstesnednftobryyoeumratyil,ppehdontaomgreaptohsinadtitcacteheydoutor aegmreaeil,moernot.ther
    electronic forms of communication, will be accepted as and carry the same weight as original signed documents.
    Electronically-signed documents and/or electronic copies of hand-signed documents, including but not limited to scanned attachments sent by email, photographs attached
    to email, or other electronic forms of communication, will be accepted as and carry the same weight as original signed documents. 


    ​

Submit
Copyright © 2014
  • Home
    • Contact Me
    • Office Hours
    • About Me
  • Blog
  • Store
  • Endurance and Run Coach
    • Wall of Fame
    • Earn Your Shirt Program
  • Functional Nutrition Coach
    • More Info: Creating Balance
  • Self-Actualization (Lifestyle Medicine) Coach
    • Mental Fitness Coach
  • "Run-60" Training Plan
  • Testimonials
  • Coach Mentorship & Supervision
    • H&W Coach Mentorship & Supervision
    • Endurance Coach Mentorship & Supervision
  • Creating Resilience Groups
    • Overcoming Negativity Bias
  • Gift Certificates
  • Refer a Friend Program