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exercise programs
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Meet the Bio
blog
about
contact
running programs
Running program
Coaching
Return from injury
Pricing
exercise programs
Info
Pricing
assessment
Make an appointment
What is biokinetics
Meet the Bio
blog
about
contact
Menu
running programs
Running program
Coaching
Return from injury
Pricing
exercise programs
Info
Pricing
assessment
Make an appointment
What is biokinetics
Meet the Bio
blog
about
contact
Order once off running program
"
*
" indicates required fields
1
Your details
2
Medical screening
3
Running history
4
Goals
5
Schedule and program
6
Consent and waiver
Your Name:
*
First name
Last Name
Your email:
*
Date of birth:
*
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Cell Number:
*
Town/City/suburb:
*
Next of kin / contact person name and cell number:
*
Tick your preferred method of communication with coach
*
Whatsapp
Email
Other
If "other", please specify:
Have you been told you have a heart condition and been told you should only do physical activity recommended by a doctor?
*
Yes
No
If yes, please elaborate:
Do you experience pain in your chest with physical activity?
*
Yes
No
If yes, please elaborate:
Have you had chest pain while not doing physical in the past month?
*
Yes
No
If yes, please elaborate:
Do you loose your balance because of dizziness, or do you lose consciousness?
*
Yes
No
If yes, please elaborate:
Do you have any injuries/ joints or muscles that might worsen with physical activity?
*
Yes
No
If yes, please elaborate:
Is your doctor currently prescribing drugs for your blood pressure/heart condition?
*
Yes
No
If yes, please elaborate:
Do you know of any other reason you should not do physical activity?
*
Yes
No
If yes, please elaborate:
Are there any other health-related issues that might be a risk when exercising?
Do you have/have had running-related injuries?
*
Yes
No
If yes, please give a brief description of your injury? When, treatment, how long couldn't you run etc.)
How would you describe your running history?
*
I have never run in my life, and are starting from scratch
I have run in the past, but are starting from scratch
I sometimes run, but very sporadically
I run, but inconsistently
I run consistently every week
How many years have you been running?
*
Less than a year
1-5 years
More than 5 years
What is your best 10km time? (no older than 3 years)
*
When did you run this time?
What would you say is your "easy" pace? (the pace where you feel the most natural - not holding back or pushing)
< 4:00 min/km
4:00 - 4:29 min/km
4:30 - 4:59 min/km
5:00 - 5:29 min/km
5:30 - 5:59 min/km
6:00 - 6:29 min/km
6:30 - 6:59 min/km
7:00 - 7:29 min/km
7:30 - 7:59 min/km
> 8:00 min/km
Don't know
In the last 6 months, what does a typical week of training look like for you?
How many times per week do you run:
*
How hard are your runs? (what pace/heart rate/perceived effort)
*
What is your weekly distance (km), your shortest run and longest run per week?
*
Do you run on the road, trail or both?
*
Road
Trail
Both
Which do you prefer?
*
Road
Trail
Both
What is your favourite race distance (road running)?
*
5km
10km
Half marathon
Marathon
Ultra marathon
None
What is your personal best time for this distance?
What do you expect to get from this running program?
*
Are there any races that you want/need to train for, or needs to be considered in your program?
*
Yes
No
If yes, please list them with their dates:
What goal are you aiming for, in one sentence:
*
Are you worried about anything specific regarding your running?
*
How many days can you/would you like to run per week?
*
1
2
3
4
5
6
Whatever is necessary
Select what days in the week you can run: (select at least 3):
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Select what days in the week you can do other exercises, like strength training/Pilates: (select at least 2):
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
On what days of the week can you do a long run?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Are there anything else you feel we need to keep in mind when designing your program?
*
Consent
*
Thank you for choosing to use the services, and programs of Hannes Swanepoel, RunningSmart.co.za. I
request your understanding and cooperation in maintaining both your and my safety and health by reading
and signing the following INFORMED CONSENT AGREEMENT:
I declare that I intend to use some or all of the activities, programs and services offered by, Hannes
Swanepoel and RunningSmart.co.za and I understand that each person, (myself included), has a different
capacity for participating in such activities, programs and services. I am aware that all activities, services,
and programs offered are either educational, recreational, or self-directed in nature. I assume full
responsibility during and after my participation, for my choices to use or apply, at my own risk, any portion
of the information or instruction I receive.
I understand that part of the risk involved in understanding any activity or program is relative to my own
state of fitness or health (physical, mental or emotional) and the awareness, care and skill with which I
conduct myself in that activity or program. I acknowledge that my choice to participate in any activity,
service and program of Hannes Swanepoel and RunningSmart.co.za brings with it the assumption by me of
those risks or results stemming from this/these choice(s) and the fitness, health, awareness, care and skill
that I possess and use. In addition, I understand that I am free to withdraw from, reduce, or modify my
involvement in any program activity and I realize that I should do so upon recognition of any signs of
transient lightheadedness, fainting, chest discomfort, leg cramps, nausea, etc.
In addition, I acknowledge that I have inquired about the nature of any activity, program, or services that I
am not completely familiar with and I have been informed of any inherent risks.
I declare that I have read, understand, and agree to the contents of this INFORMED CONSENT
AGREEMENT in its entirety.
I declare that I have read, understand, and agree to the contents of this INFORMED CONSENT AGREEMENT in its entirety
Waiver of liability
ASSUMPTION OF RISKS AND RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY
AGREEMENT BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS,
INCLUDING THE RIGHT TO SUE.
PLEASE READ CAREFULLY
In regard to my preparation for and participation in the Running Training Program (herein called
“Course”), conducted by Hannes Swanepoel and RunningSmart.co.za (herein called
“Organizers”) including but not limited to the fitness activities and exercise held at the Course, I
am aware that:
a) fitness activities and exercise and participation in the Course exposes participants to many
risks and hazards, some of which are inherent in the very nature of the training required, the
Course, and fitness activities and exercise
itself; others which result from human error and negligence on the part of the persons involved
in preparing, organizing and staging fitness activities and exercise;
b) as a result of the aforesaid risks and hazards, I as a participant may suffer serious personal
injury (even death) or property loss;
c) some of the aforesaid risks and hazards are foreseeable, but others are not;
d) I nevertheless freely and voluntarily assume all the aforesaid risks and hazards, and the
possibility of personal injury, death, property damage or loss, resulting therefrom and that,
accordingly, my preparation for and participation in the aforesaid fitness activities and exercise
and Course shall be entirely at my own risk; and
e) I understand that the ORGANIZERS (Hannes Swanepoel and RunningSmart.co.za) its officers,
directors, employees, independent contractors, agents, affiliated clubs, sponsors, or volunteers
do not assume any responsibility whatsoever for my safety during the course of my preparation
for or participation in the aforesaid fitness activities, exercise or Course.
Release of Liability, Waiver of Claims And Indemnity Agreement
I hereby acknowledge and agree, in consideration of being permitted to participate in the
Course, as follows:
1. TO WAIVE ANY AND ALL CLAIMS, known or unknown, that I may have or may in the future
have against the ORGANIZERS.
2. TO RELEASE THE ORGANIZERS from any and all liability for any and all personal injuries, loss,
damage, expense or injury including death that I may suffer or that my next of kin may suffer
resulting from or arising out of my preparation for or participation in the Course DUE TO ANY
CAUSE WHATSOEVER, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY
STATUTORY OR OTHER DUTY OF CARE, ON THE PART OF THE ORGANIZERS, AND ALSO INCLUDING THE FAILURE ON THE PART OF THE ORGANIZERS TO SAFEGUARD OR PROTECT ME
FROM THE RISKS, DANGERS AND HAZARDS OF FITNESS ACTIVITIES AND EXERCISE REFERRED TO
ABOVE.
3. TO BE LIABLE AND TO HOLD HARMLESS AND INDEMNIFY THE ORGANIZERS from any and all
liability for any damage to property of, or personal injury to, any third party, resulting from or
arising out of my preparation for and participation in the Course.
4. Each section, part, term and/or provision of this Agreement will be considered severable and
fully-enforceable. In the event that any one or more of the provisions contained herein shall, for
any reason, be held to be invalid, illegal or unenforceable in any respect, such invalidity,
illegality or unenforceability shall not affect any other provisions of this Agreement, but this
Agreement shall be construed as if such invalid, illegal or unenforceable provisions had never
been
contained herein.
5. This Agreement shall be effective and binding upon my heirs, next of kin, executors,
administrators and personal representatives in the event of my death or incapacity.
6. This Agreement and any rights, duties and obligations as between the parties to this
Agreement shall be governed by and interpreted solely in accordance with the laws of the
Republic of South Africa. Any litigation involving the parties to this Agreement shall be brought
solely within the Republic of South Africa and shall be within the exclusive jurisdiction of the
Courts of the Republic of South Africa. In entering into this Agreement I am not relying upon
any oral or written representations or statements made by the ORGANIZERS with respect to the
safety of fitness activities and exercise and the preparation for and the participation in the
Course, other than what is set forth in this Agreement.
I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS
AGREEMENT I AM ASSUMING CERTAIN RISKS AND WAIVING CERTAIN LEGAL RIGHTS WHICH I
MAY HAVE AGAINST THE ORGANIZERS.
I have read and understand this AGREEMENT and I am aware that by signing this THIS AGREEMENT I AM ASSUMING CERTAIN RISKS AND WAIVING CERTAIN LEGAL RIGHTS WHICH I MAY HAVE AGAINST HANNES SWANEPOEL AND RUNNINGSMART.
Name
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