Name:
Date of Birth:
E-mail Address:
Home Address 1:
Home Address 2:
Town/City:
Postcode:
Country:		Australia     NZ     UK     Other
Daytime Contact No.:		(please include country & area codes)

Name:
Date *:		day (1-31)    month (1-12)    year (2008-2099) (*) We need to know this so we can accurately map your plan and calculate your fee
Distance:		Miles    Km
Target time:

Please give details of all major injuries, illnesses, allergies here:

Please give details of family history of heart disease, stroke, diabetes and high blood pressure here:

Have you ever been told not to exercise by a doctor or medical expert?    Yes    No

Do you know of any reason you shouldn't run?    Yes    No

Please give details of the fitness training you have done in the last 12 months here:

Is there any other fitness training you've done in the past that you need to tell us about?

If you have entered running events before, give details of the last 3 events:

Date:     Distance:     Time: hr min

Date:     Distance:     Time: hr min

Date:     Distance:     Time: hr min

How many times a week can you commit to training for this event?

Are there any days of the week you are NOT able to train? Let us know now so we can exclude them from your plan.

Will you be continuing any other fitness training in this time? Let us know what days and what type of training.