Assessment

Initial Coaching Assessment and Waiver of Liability

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Emergency Contact Name *

First

Last

Relationship? *

Phone Number *

How did you find Creating Momentum Coaching? *

If you selected "Other", please explain: *

Running and Fitness History

Previous Fitness and/or Athletic History *

Gender *

Age *

Height *

Weight *

How long have you been running? *

Highest Weekly Mileage Reached? *

Did you take any extended breaks from running? How long and for what reason? *

List your Most Recent Race Performances in last 6 months (Please include the Race Name & Distance, Terrain, Time/Pace, Date): *

When did you reach your high mileage and was a race included? *

List Your Lifetime Personal Best Race Performances (Please include the Race Name & Distance, Terrain, Time/Pace, Date) *

Describe your Fitness Goals (include Race Names, Dates, Distances, and Time goals, if applicable). *

What obstacle prevent you from achieving your Goals? *

Describe your Coach-Client expectations (what are you hoping a Coach can do for you?) *

Describe your support systems and/or strengths that will help you achieve your Goals! *

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

Mon *

Tues *

Wed *

Thur *

Fri *

Sat *

Sun *

Total *

Three
Weeks
Ago

Comment *

2 weeks ago

Last Week

Available Training Time

Lifestyle

ATTESTATION OF GOOD HEALTH

Any Additional Questions or Comments *

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
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Print Name: ____________________________________________
Signature*: ____________________________________________ ____________________________

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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
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Submit

​Initial Coaching Assessment and Waiver of Liability

Running and Fitness History​

ATTESTATION OF GOOD HEALTH

Waiver......

Initial Coaching Assessment and Waiver of Liability

Running and Fitness History