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Sports Club Questionnaire

Instructions

Competitive Tier and Elite Development runners wishing to join the Kiprunning Sports Club must complete the following questionnaire as part of the entry process. Coach Komen will use this information to evaluate your running history, current level of fitness, and general health. Please answer the questions on this form completely and as specifically as possible. Likewise, when listing your race performance times, please, whenever possible, include valid URLs to your official race results.

The information gathered here will be used solely by Wilson Komen for determining your qualifications for the Kiprunning Sports Club. He will not share your information with any other person or entity. Your personal information is strictly confidential. If you have any questions or concerns about completing this form, please contact Coach Komen.

Please note that the coaching provided by Wilson Komen of Coach Kiprunning is not intended in any way as a substitution for professional medical advice. If you have questions or concerns about your exercise regimen, personal nutrition, injury status, or your overall health, please contact your primary care physician for further assistance.

The Questionnaire

Name *

First

Last

Street Address 1 *

This field only requires a street address. Add any apartment number information in the optional "street address 2" field.

Street Address 2

Please enter your apartment number, if appropriate, here.

City *

State *

Postal Code *

Country *

Phone Number *

Please enter your phone number, complete with area code and, as necessary, country code.

Email Address *

Confirm Email

Age *

Sex *

Height *

Weight *

Resting Heart Rate *

Relevant Illnesses and Medications *

This information will help Coach Wilson design an appropriate training regimen. Please complete this field, or enter "n/a."

Currently Injured? *

Please enter either "yes" or "no."

Injury Type and Prognosis (if relevant)

If relevant, please be detailed. Indicate the type of injury, treatment plan, duration of recovery, and date to return to running.

Additional Injury Comments (optional)

Feel free to add any comments about your injury history or current injury status that you think will be helpful to Coach Komen.

Total Years Running *

Average Miles Per Week *

Rough averages are perfectly acceptable.

Distances Raced (list all) *

Current Racing Goals *

5KM Personal Record

For the 5KM distance and each of the following, include your personal records (according to official race finish times), name of race, and (wherever possible) accurate URLs for your race results. Type "n/a" if not relevant.

8KM PR

10KM PR

10 Mile PR

Half Marathon PR

Full Marathon PR

Personal Coaching Experience *

Discuss experience with past personal running coaches. If none, explain why you are seeking personal coaching. What are your competitive running goals?

Reason for Joining the Kiprunning Sports Club *

Prior Team Experience *

Describe any prior team training and racing experience. Memberships on school-affiliated teams as well as recreational running clubs are all valid experience.

Additional Comments (optional)

Feel free to add any additional comments about your training, racing, or medical history that you think will helpful to Coach Komen.

Name