Mental Game Training, run, running, racing, triathlon, triathlons, mental training, mental game, sport psychology, mental toughness, mental coaching, coach, running coach, mindset, cross-country, cross country, x-country, XC, road racing, ironman, iron man, duathlon, focus, concentration, refocus, Coach Dean, MGCP, mental training, mental game preparation, race anxiety, tension, race nerves, mind set<TITLE>
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<p align="left" class="heading2"><font color="#BA2F04" size="3"><strong><br>
Intake Form</strong></font></p>
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<td>
<p>This form provides basic relevant information. In order
that we can provide you with the highest quality coaching
possible, please complete the entire form to the best
of your ability. This begins the coaching dialogue and
process. </p>
<form action="emailformdata.php" method="post" name="MailForm" width="640">
<hr>
<p class="bodyEmphasis"><b>A. General Information</b></p>
<p>In which sport do you desire training?
<select name="Training Desired" size="1">
<option value="Running">Running </option>
<option value="Multisport">Multisport </option>
<option value="Health and Fitness">Health and Fitness
</option>
<option value="Other">Other </option>
</select>
</p>
<p>Which training plan have you selected?
<select name="Training Selected" size="1">
<option value="Monthly">Monthly</option>
<option value="Assessment">Assessment</option>
<option value="Race-specific Package">Race-specific
Package</option>
<option value="Boston Qualifier">Boston Qualifier</option>
</select>
</p>
<p> </p>
<table border="0" cellpadding="0" cellspacing="4">
<tr>
<td align="right" class="bodyCopy">Name</td>
<td align="left">
<input type="text" name="Name" size="24">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Address</td>
<td align="left">
<input type="text" name="Address1" size="24">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy"></td>
<td align="left">
<input type="text" name="Address2" size="24">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">City</td>
<td align="left">
<input type="text" name="City" size="24">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">State</td>
<td align="left">
<input type="text" name="State" size="4">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Zip</td>
<td align="left">
<input type="text" name="Zip" size="10">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Date</td>
<td align="left">
<input type="text" name="Date" size="15">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Home Phone #</td>
<td align="left">
<input type="text" name="Home Phone" size="12">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Work Phone #</td>
<td align="left">
<input type="text" name="Work Phone" size="12">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Cell Phone #</td>
<td align="left">
<input type="text" name="Work Phone2" size="12">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Fax #</td>
<td align="left">
<input type="text" name="Fax" size="12">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">E-mail</td>
<td align="left">
<input type="text" name="Email" size="24">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Gender</td>
<td align="left">
<select name="Gender" size="1">
<option value="Male">Male
<option value="Female">Female
</select>
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Date of Birth</td>
<td align="left">
<input type="text" name="Birth Date" size="15">
</td>
</tr>
<tr>
<td align="right" class="bodyCopy">Age</td>
<td align="left">
<input type="text" name="Age" size="3">
</td>
</tr>
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<td align="right" class="bodyCopy"></td>
<td align="left"></td>
</tr>
<tr>
<td align="right" class="bodyCopy"></td>
<td align="left"></td>
</tr>
</table>
<hr>
<p class="bodyEmphasis"><b>B. Medical History</b></p>
<p>Please list any medications, drugs or nutritional supplements that you are presently taking.<br>
<textarea name="Medications Taking" cols="60" rows="4"></textarea>
</p>
<p>Is your physician aware that you are participating
in this exercise program?
<input type="text" name="Doctor Aware" size="10">
<br>
</p>
<p>Explain any past injuries or surgeries affecting working
out. Include dates or time frames as best possible.<br>
<textarea name="textarea" cols="60" rows="8"></textarea>
</p>
<p>If currently exercising, briefly describe your program:<br>
<textarea name="Exercise Program" cols="60" rows="8"></textarea>
</p>
<p> </p>
<hr>
<p class="bodyEmphasis"><b>C. Physiology</b></p>
<p>What is your current body weight?
<input type="text" name="body weight" size="5">
<br>
</p>
<p>What is your height?
<input type="text" name="body height" size="5">
<br>
</p>
<p>Do you know your numerical value for V02 max (ml/kg/)?
<input type="text" name="V02 max" size="5">
<br>
</p>
<p>What is your Body Mass Index (BMI)?
<input type="text" name="Current Body Fat2" size="5">
</p>
<p>Do you know your current body fat percentage?
<input type="text" name="Current Body Fat" size="5">
</p>
<p><b>If you use a heart monitor:</b><br>
</p>
<p>What is the max heart rate (running) you have seen
in the past 6 months?
<input type="text" name="RUN Max Heart Rate 6 Months" size="5">
<br>
<br>
What is the max heart rate (running) you have ever seen?
<input type="text" name="RUN Max Heart Rate Ever" size="5">
<br>
<br>
</p>
<p> </p>
<hr>
<p class="bodyEmphasis"><b>D. Training Information</b></p>
<p>How many years have you been running?
<input type="text" name="Years Running" size="5">
</p>
<p>How many miles per week are you running?
<input type="text" name="Miles per Week Running" size="5">
</p>
<p>How many hours per week are you running?
<input type="text" name="Hours per Week Running" size="5">
</p>
<p>What is your average run length in miles and time?
<input type="text" name="Hours per Week Running2" size="5">
<input type="text" name="Avg Run Length and Time" size="24">
</p>
<p>What is your long run length in miles and time?
<input type="text" name="Hours per Week Running22" size="5">
<input type="text" name="Long Run Length and Time" size="24">
</p>
<p>What are your PRs (Personal Records) for the following
distances with approximate dates? (Leave blank if not
applicable.)</p>
<table width="94%" border="0">
<tr>
<td width="36%">
<div align="center">Race</div>
</td>
<td width="33%">
<div align="center">Times</div>
</td>
<td width="31%">
<div align="center">Dates</div>
</td>
</tr>
</table>
<table width="94%" border="0">
<tr>
<td width="36%">
<div align="right">400</div>
</td>
<td width="33%">
<input type="text" name="400 Time" size="30">
</td>
<td width="31%">
<input type="text" name="400 Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">800</div>
</td>
<td width="33%">
<input type="text" name="800 Time" size="30">
</td>
<td width="31%">
<input type="text" name="800 Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">1600</div>
</td>
<td width="33%">
<input type="text" name="1600 Time" size="30">
</td>
<td width="31%">
<input type="text" name="1600 Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">3000 (3K)</div>
</td>
<td width="33%">
<input type="text" name="3000 Time" size="30">
</td>
<td width="31%">
<input type="text" name="3000 Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">3200</div>
</td>
<td width="33%">
<input type="text" name="3200 Time" size="30">
</td>
<td width="31%">
<input type="text" name="3200 Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">5000 (5K)</div>
</td>
<td width="33%">
<input type="text" name="5000 Time" size="30">
</td>
<td width="31%">
<input type="text" name="5000 Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">10K</div>
</td>
<td width="33%">
<input type="text" name="10K Time" size="30">
</td>
<td width="31%">
<input type="text" name="10K Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">10 Mile</div>
</td>
<td width="33%">
<input type="text" name="10 Mile Time" size="30">
</td>
<td width="31%">
<input type="text" name="10 Mile Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Half-Marathon</div>
</td>
<td width="33%">
<input type="text" name="Half Marathon Time" size="30">
</td>
<td width="31%">
<input type="text" name="Half Marathon Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Marathon</div>
</td>
<td width="33%">
<input type="text" name="Marathon Time" size="30">
</td>
<td width="31%">
<input type="text" name="Marathon Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Ultra-Distance/Event</div>
</td>
<td width="33%">
<input type="text" name="Ultra Distance Event Time" size="30">
</td>
<td width="31%">
<input type="text" name="Ultra Distance Event Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Other Distance/Event</div>
</td>
<td width="33%">
<input type="text" name="Other Distance Event Time" size="30">
</td>
<td width="31%">
<input type="text" name="Other Distance Event Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Sprint Tri</div>
</td>
<td width="33%">
<input type="text" name="Sprint Tri Time" size="30">
</td>
<td width="31%">
<input type="text" name="Sprint Tri Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Olympic Tri</div>
</td>
<td width="33%">
<input type="text" name="Olympic Tri Time" size="30">
</td>
<td width="31%">
<input type="text" name="Olympic Tri Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Half Ironman Tri</div>
</td>
<td width="33%">
<input type="text" name="Half Ironman Tri Time" size="30">
</td>
<td width="31%">
<input type="text" name="Half Ironman Tri Date" size="30">
</td>
</tr>
<tr>
<td width="36%">
<div align="right">Ironman Tri</div>
</td>
<td width="33%">
<input type="text" name="Ironman Tri Time" size="30">
</td>
<td width="31%">
<input type="text" name="Ironman Tri Date" size="30">
</td>
</tr>
</table>
<p> Describe your typical warm-up routine here.
<textarea name="Running PR " cols="40" rows="4"></textarea>
</p>
<hr>
<p class="bodyEmphasis"><b>E. Performance Support Information</b></p>
<p>When was the last time you replaced your shoes?
<input type="text" name="last time replaced shoes" size="5">
</p>
<p>Are there specific exercises you are unable to perform? If so, what
are they?<br>
<textarea name="Specific exercises unable to perform" cols="60" rows="4"></textarea>
<br>
</p>
<p>Name of fitness club membership (if applicable)?
<input type="text" name="Fitness club membership" size="30">
</p>
<p>Do you have any exercise equipment at home? Please list.<br>
<textarea name="Excercise Equipment at Home" cols="40" rows="4"></textarea>
</p>
<p>Describe how much time are you willing to allocate
to fitness activities in hours per day; weekdays; on
weekends. Please include information about the time
of day you prefer to workout as well as your work schedule,
frequent travel, etc.<br>
<textarea name="Time to Allocate for Fitness" cols="60" rows="4"></textarea>
</p>
<p>Do you consider yourself a beginner, intermediate or
advanced athlete?
<input type="text" name="Type of Athlete" size="12">
</p>
<p><br>
</p>
<p>What are some secondary activities you want to incorporate
into your training plan?<br>
<textarea name="Secondary Activities" cols="40" rows="4"></textarea>
<br>
</p> <p>What type of events do you want to focus on and what are the distances
of these events?<br>
<textarea name="Type and Distance of Events" cols="40" rows="4"></textarea>
<br>
</p>
<p>List races you intend participating in during the next
12 months. Please list events, dates, location, and
terrain if known. Please prioritize events in order
of importance.<br>
<textarea name="Upcoming Events" cols="40" rows="4"></textarea>
<br>
</p>
<p>What are your specific goals for the events mentioned above (finish times, etc.)?<br>
<textarea name="Goals for Events" cols="40" rows="4"></textarea>
<br>
</p>
<p>How many events did you participate in last year?<br>
<textarea name="Number of Events Last Year" cols="40" rows="4"></textarea>
<br>
</p>
<p>Do you live in region where the weather can affect training? Please describe.<br>
<textarea name="Weather" cols="40" rows="4"></textarea>
</p>
<p>Do you own an indoor trainer or treadmill?
<select name="Own an indoor trainer or treadmill">
<option value="Yes">Y</option>
<option value="No">N</option>
</select>
<br>
</p>
What other athletic activities have you been doing for the past 2 months
and how much of each?<br>
<textarea name="Other Activities Past 2 Months" cols="40" rows="4"></textarea>
<p>What are your expectations regarding this relationship?<br>
<textarea name="Expectations of Relationship" cols="40" rows="4"></textarea>
</p>
<p>If you have any specific goals/concerns/etc., please list them.<br>
<textarea name="Goals or Concerns" cols="40" rows="4"></textarea>
<br>
</p>
<p>Why do you participate in races and/or training?<br>
(To select multiple items: <i>ctrl</i> click Windows - <i>cmd</i> click Mac)<br>
<select name="Why Participate" size="4" multiple>
<option value="Social Aspects">Social Aspects</option>
<option value="Enjoy competition">Enjoy competition
</option>
<option value="Fitness">Fitness </option>
<option value="Weight loss">Weight loss </option>
<option value="I enjoy travelling to races">I enjoy
traveling to races </option>
<option value="Personal Improvement">Personal Improvement</option>
<option value="To win or beat competitors">To win
or beat competitors</option>
</select>
</p>
<p>What form of communication do you want from your coach?<br>
(To select multiple items: <i>ctrl</i> click Windows - <i>cmd</i> click Mac)<br>
<select name="Forms of Communication" size="4" multiple>
<option value="Email">E-mail
<option value="Phone">Phone
<option value="Mail">Mail
<option value="Fax">Fax
</select>
</p>
<p>When would you like your training program to begin?
<input type="text" name="When to Begin" size="24">
<br>
</p>
<p>Please list any additional comments and or concerns that will assist us in helping you reach your goals.<br>
<textarea name="Additional Comments" cols="40" rows="4"></textarea>
</p>
<hr>
<p class="bodyEmphasis"><b>F. Payment Policy</b></p>
The programs are based on monthly cycles. We request athletes
to commit to a minimum of 4 months(17 weeks). New programs
may see immediate results but results are far superior
over longer periods. These payments need to be made before
the beginning of the next training schedule. The training
schedule is but one part of the coaching package. <br>
<hr>
<p class="bodyEmphasis"><b>G. Waiver and Release of Liability, Assumption
of Risk and Indemnity</b></p>
<strong>Athletes over the age of 18.</strong><br>
I acknowledge that by signing this document, I am releasing
RxRunning and Mindset for Performance LLC and all of its
respective agents and employees from liability. I have
been advised by RxRunning and Mindset for Performance
LLC that it is my responsibility to seek a physicians
advise before beginning this or any exercise or training
program. By signing this document I hereby fully assume
any and all risks associated with my participation with
RxRunning and Mindset for Performance LLC. I hereby waive,
release, discharge, hold harmless, and indemnify RxRunning
and Mindset for Performance LLC from any and all claims
arising, and from any and all damages which may be sustained
directly or indirectly or out of my association with RxRunning
and Mindset for Performance LLC.<br>
<br>
<strong>Athletes under the age of 18.</strong><br>
Please read the Waiver and Release of Liability for Athletes over the age of 18 and then read this section.<br>
In addition to the waiver and release of liability, if
the athlete is under the age of eighteen (18), written
permission in the form of a signature to this agreement
by the minor athlete's parent or legal guardian is required
prior to the minor athlete's participation in these services.
Minor athlete's parent and/or legal guardian, hereby waive,
release, discharge, hold harmless, and indemnify RxRunning
and Mindset for Performance LLC and all its respective
agents, employees, and all other associates from any and
all damages which may be sustained directly or indirectly
or out of his/her association with RxRunning and Mindset
for Performance LLC.<br>
</p>
<hr>
<p class="bodyEmphasis"><b>H. Required</b></p>
By selecting the I agree box below, I (participating athlete or legal guardian of a minor athlete) understand and agree to the terms of this waiver and the payment policy (section F and section G). <input type="checkbox" value="Yes" name="Accept Waiver"><strong> I AGREE</strong><input type="hidden" name="success" value="http://www.pyramidcoaching.com/thankyou.html">
<p><input type="submit" name="submit"> <input name="reset" type="reset"></p>
<span class="bodyEmphasisRed">CHECK THE I AGREE BOX BEFORE SUBMITTING FORM </span>
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