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2021 SportMedBC InTraining Program Waiver

RELEASE OF LIABILITY, WAIVER OF CLAIMS, DECLARATION of HEALTH AND ASSUMPTION OF RISKS. BY AGREEING TO PARTICIPATE IN SPORTMEDBC’S INTRAINING PROGRAM YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ CAREFULLY.

I understand, accept and agree that participating in The SportMedBC InTraining Program by any means, including, but nFoLtIP PAGE→ limited to, as a runner, jogger, walker, in a wheelchair or with a stroller, is a potentially hazardous activity. I represent, warrant, covenant
and agree that I am participating in The SportMedBC InTraining Program entirely of my own choice and volition and that it has
not been requested, suggested or required in any way that I participate, including by SportMedBC. I understand that participation in The SportMedBC InTraining Program may challenge and engage my physical and mental resources. I confirm that I do not have any medical conditions that would prevent me from safely participating in The SportMedBC InTraining Program including, but not limited to, stroke, high blood pressure, heart, liver, kidney or thyroid disease, diabetes, or anemia, including a family history of any of the above or other medical conditions. I specifically confirm and declare that I am not ill with, nor have been exposed to the Covid-19 virus, or other contagious illness, within the past 14 days. I am not taking nor do I plan to take any prescription, OTC and/or other herbal medications that could affect my safe participation in The SportMedBC InTraining Program. I understand the risks and danger of accidents, physical injury, effects of exercise, the unpredictable nature of the human body, possible exposure to Covid-19 or other contagious illness, and the activities inherent in the nature of running and participating in a running program, and I understand it is impossible for the Releasees (defined below) to guarantee my safety. I further understand that I should not participate in The SportMedBC InTraining Program if I have any health conditions affecting my ability to safely participate and that I should not participate unless I am medically able and properly trained. I also understand that there may be traffic on the course. I assume all risks of participating in The SportMedBC InTraining Program whether jogging, running, walking or traveling in a wheelchair or with a stroller, including in traffic. I also assume any and all other risks associated with participating in The SportMedBC InTraining Program, including, but not limited to, falls, injury, contact with other participants or persons, becoming exposed to or ill with Covid-19 or other contagious illness, the effects of the weather including rain, snow, ice, high heat and/or humidity and the condition of the roads or racing surfaces and events that may be unforeseeable or beyond the control of the Releasees (as defined below) including “Acts of God”, civil unrest and third party violence or terrorism. Knowing these risks, and in consideration of the acceptance of my entry in this clinic, I hereby remise, release, indemnify, forever discharge and hold harmless SportMedBC, the City of Vancouver including its Police Department, Emergency Radio Systems, race officials, race volunteers and all other associated program sponsors, and each of their respective parent companies, subsidiaries, affiliates, agents, directors, employees, assigns or anyone else acting for or on their behalf (the “Releasees”) from and against any and all existing and future claims, actions, costs, suits, demands and/or liability (including reasonable solicitor fees and legal costs), including from any and all claims from any third party, for loss, harm, damages, cost or expense, including, without limitation injuries, accidents, losses and damages related to personal injuries, death, damage to, loss or destruction of property, rights of publicity or privacy, defamation, or portrayal in a false light which I, my heirs, executors, administrators, personal representatives, successors or assigns, now have, or may hereafter have, arising out of the acts or omissions, including negligence of the Releasees. I consent to the use, broadcast, distribution, exhibition or exploitation of any recordings, photographs, videotapes of me or other record of this event, and/or my participation in The SportMedBC InTraining Program or related events and grant full permission to SportMedBC, and/or agents authorized by them, to use my name and/or likeness, and/or any photographs, videotapes, motion pictures, recordings, or any other record of this event, of me, for any legitimate purpose related to The SportMedBC InTraining Program, without any compensation to me.

MEDICAL TREATMENT: If I am unable to consent at the time due to injury or illness, I hereby consent to the administration of first aid and other emergency medical treatment for any injury or illness that occurs during any of my participation in The SportMedBC InTraining Program. Further, I hereby release and forever discharge the Releasees Parties from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered as contemplated hereunder. This Release and its application and interpretation will be governed exclusively by the laws of British Columbia and the parties agree to the jurisdiction of the courts of the Province of British Columbia

I Agree
 I HEARBY ACKNOWLEDGE HAVING READ THIS RELEASE AND WAIVER. I UNDERSTAND THAT, BY REGISTERING FOR THE SPORTMEDBC INTRAINING PROGRAM, I ACCEPT ITS TERMS. I FURTHER ACKNOWLEDGE AND AGREE TO THE TERMS OF THIS RELEASE AND WAIVER ON BEHALF OF MY MINOR CHILD, IF APPLICABLE

I Agree
I HAVE READ THE CONDITIONS OF ENTRY FOR THE SPORTMEDBC INTRAINING PROGRAM, AND I UNDERSTAND AND AGREE TO BE BOUND BY THEM

COVID-19 Questionnaire, Attestation and Participant Agreement

Application - all SportMedBC’s Members (athletes, training, coaches, officials, associates) and family members (“Participants”) of those in attendance at club/training group activities.

I attest that I, or as the case may be my minor child Participant indicated below (collectively “Participant”) am not experiencing any symptoms of illness such as a fever, cough, difficulty breathing, shortness of breath or malaise (severe fatigue or feeling of being generally unwell).

If Participant develops these symptoms, I agree that Participant will leave the premises immediately and immediately inform Medical Health Officer (or delegate) at your local health authority.

I am aware that Participant must follow the safety and hygiene protocols of the Province of British Columbia, the Provincial Health Officer, and the SportMedBC’s 2021 InTraining Program.

I attest that:

• Participant has not travelled internationally in the past fourteen (14) days.
• Participant has not travelled outside the Province of British Columbia in the last fourteen (14) days.
• Participant has not travelled to an area highly impacted by COVID-19 within my Province in the past fourteen (14) days.
• I have not and do not believe that Participant has been exposed to a person with a confirmed or suspected case of COVID-19.

I attest that:

• Participant has not been diagnosed with COVID-19

OR

• Participant has been diagnosed with COVID-19 and been cleared as noncontagious by provincial or local public health authorities (confirmation from a medical practitioner will be required and maintained in a confidential file by the organization)

I acknowledge and agree that Participant will follow recommended guidelines, laws and protocols of the Province of British Columbia, the Provincial Health Officer, and SportMedBC in order to reduce the spread of COVID-19.

All Participants of the SportMedBC’s 2021 Training Program agree to abide by the following points when entering training facilities, clinic host locations and/or participating in club/training group activities under the COVID-19 Response plan and RTP Protocol:

  • Participant agrees to symptom screening checks and will let SportMedBC, their clinic coordinator/training group know if they have experienced any of the symptoms in the last 14 days.
  • Participant agree to stay home if feeling sick and remain home for 14 days if experiencing COVID-19 symptoms.
  • Participant agrees to sanitize their hands upon entering and exiting the facility/group training session, with soap & water or sanitizer.
  • Participant agrees to sanitize the equipment (shared and personal equipment) they use throughout their practice with approved cleaning products provided by SportMedBC/training group.
  • Participant agrees to continue to follow social distancing protocols of staying at least 2m away from others.
  • Participant agrees to not share any equipment during practice times.
  • Participant agrees to abide by all of SportmedBC’s and their clinic host locations' COVID-19 Policies and Guidelines.
  • Participant understands that if they do not abide by the aforementioned policies/guidelines that they may be asked to leave the clinic/training group for up to 14 days to help protect the participant and others around them.
  • Participant acknowledges that continued abuse of the policies and/or guidelines may result in the temporary suspension of their Program participation.
  • Participant acknowledges that there are risks associated with entering training facilities and/or participating in program/training group activities, and that the measures taken by SportMedBC’s training clinics and participants, including those set out above and under the COVID-19 Response Plan and Return to Sport Protocols, will not entirely eliminate those risks.

I acknowledge that the foregoing statements are true.

I Agree

Date of Signature: October 26, 2021 

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Parent or Guardian's Email Address

Email*

Confirm Email*
I agree to receive e-mail updates, and other Commercial Electronic Messages, pertaining to the SportMedBC LearnToRun10K Program from SportMedBC and its Contractors (Management Staff, Clinic Coordinators, and/or Leaders when applicable). I understand that I may withdraw my consent at any time.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please Select*
I AM A NEW RUNNER (OR HAVE NOT RUN IN THE PAST 6 MONTHS)
I HAVE BEEN RUNNING IN THE PAST 6 MONTHS

HOW DID YOU HEAR ABOUT THIS PROGRAM?

DO YOU HAVE ANY QUESTIONS/CONCERNS/HESITATIONS ABOUT THIS PROGRAM OR ABOUT STARTING A RUNNING PROGRAM?
DO YOU CURRENTLY HAVE, OR HAVE A HISTORY OF, ANY OF THE FOLLOWING (CHECK ANY THAT APPLY):
ALLERGIES
ARTHRITIS
ASTHMA
CHEST PAIN
DIABETES
DIZZINESS
EPILEPSY
FAINTING SPELLS
HEART CONDITION / PROBLEM
HEPATITIS
KIDNEY DISORDER / ILLNESS
NECK / BACK DISORDER SEIZURES
TEMPERATURE REGULATION PROBLEM
THYROID DISORDER
ULCERS
RECENT WITHIN ONE YEAR:
INFECTIOUS DISEASE
HEAD INJURY
CONCUSSION
MAJOR SURGERY
PREGNANCY
MUSCULAR INJURY
BROKEN BONE (S)
ARE YOU CURRENTLY DEALING WITH ANY MUSKULOSKELETAL INJURIES/CONDITIONS?*
No
Yes

IF YES, PLEASE SPECIFY:
ARE YOU CURRENTLY PREGNANT?
HAVE YOU EVER BEEN TOLD BY A DOCTOR NOT TO PARTICIPATE IN PHYSICAL ACTIVITY?*
No
Yes

IF YES, WHY?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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