Running Health Information Form

Running Health Information Form
1. Please describe the current state of your health:
2. Are you taking any long-term prescription or over-the-counter medication?
If so, please list the medication and reason you are taking it.
3. Please describe any other health or medical condition(s) below:
4. Please ask any questions or voice any concerns that you have about participating in these running sessions:
5. Is there anything else I should know about you or your health?

6. What would you like most out of your running session?
7. Please circle what is important to you:

Speed Stamina Flexibility Enjoyment Strength Energy Breathing Relaxation Injury Prevention Weight Loss
8. Emergency contact information
Phone Number

Area Code Phone Number
Name

First Name Last Name
9. Your details
Name

First Name Last Name

Address

10. I consent to my photo being used for advertising purposes e.g. Website/Facebook/Instagram?
11. Keep in touch with us Please tick the boxes below to tell us all the ways you would prefer to hear from us:
This data is securely stored and only accessible to ZOGI, we do not share personal data with any third party. If you no longer want us to hold your information, we will securely destroy it.
I consent to you holding the attached information, for the purposes of attending your running sessions.
DateTime
Signed:

Clear
Should be Empty:

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