Athlete Intake Form | Carolina Multisports

Athlete Intake Questionnaire

All information submitted will be kept confidential.

Step 1 of 7 – Contact Information

Date*
MM slash DD slash YYYY
Name*
First Last
USAT Membership Number
If you have an annual membership, please provide your membership number.
T-Shirt Size
Birthday*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Email*
Preferred Method of Communication
Best days/times to speak
Emergency Contact Information*
Name, relationship, cell phone, work phone.

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Primary Care Physician Name
Prefix First Last Suffix
Primary Care Physician Phone
Primary Care Physician Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you currently taking any medications/supplements? If so, please list medication name, dose, frequency, and reason for taking:*
Do you have any allergies? If so, please list:
Briefly describe past and current medical history, including any major illnesses, surgeries, or past medical problems and injuries:
Have you ever had a heart condition, chest pain, or high or low blood pressure, dizziness, recent surgery, pregnancy or injury? If so, please describe?
Have you experienced any emotional/mental health concerns that may affect your training? If so, please describe:
Have there been significant changes in your diet? Have you ever been diagnosed with an eating disorder?
Are you currently experiencing any injuries? If so, please describe injury, date of injury, and treatment plan?
Are you aware, through your own experience or doctor’s advice, of any other pertinent information that may be helpful to address? Please explain.

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Waiver*
I hereby take the following action for Joel Young and/or Carolina Multisports, LLC, otherwise known as CM, their executors, administrators, partners, contractors, employees, heirs, next of kin, successors and assigns, or anyone else who might claim or sue on their behalf, and I expressly acknowledge that it is my intent to take these actions:

(a) WAIVE, RELEASE, AND DISCHARGE FROM ANY AND ALL CLAIMS, LOSSES, OR LIABILITIES FOR DEATH, PERSONALLY INJURY, PARTIAL OR PERMANENT DISABILITY, PROPERTY DAMAGE, MEDICAL OR HOSPITAL BILLS, THEFT OR DAMAGES OF ANY KIND, INCLUDING ECONOMIC LOSSES AND LOSS AND/OR STOLEN ITEMS WHICH ARISE OUT OF OR RELATE TO MY PARTICIPATION IN THE PRESCRIBED TRAINING PLANS, TESTS, CLASSES, AND PROGRAMS: Joel Young, and/or Carolina Multisports, LLC, their executors, administrators, partners, contractors, employees, heirs, next of kin, successors and assigns, or anyone else who might claim or sue on their behalf.

I ALSO ASSUME ANY AND ALL OTHER RISKS associated with participating in fitness classes and/or athletic events including but not limited to falls, contact and/or crashes with other participants, effects of weather including heat and/or humidity, defective equipment, the condition of the roads and railroad crossings, water hazards, contact with other swimmers or boats, and any hazard that may be posed by spectators of volunteers all such risks being known and appreciated by me, and I further acknowledge that these risks include those that may be the negligence of the persons or entities mentioned above in paragraph (a) or persons or entities; (b) I AGREE NOT TO SUE ANY OF THE PERSONS OR ENTITIES MENTIONED ABOVE IN PARAGRAPH (a) for any of the claims, losses, or liabilities that I have waived, released or discharged herein; and (c) I INDEMNIFY AND HOLD HARMLESS THE PERSONS AND ENTITIES MENTIONED IN PARAGRAPH (a) for any and all claims made or liabilities assessed against them as a result of (i) my actions or inaction’s, (ii) the actions, inactions, or negligence of others including those parties hereby indemnified; (iii) the conditions of the facilities, equipment, CM vehicles, or areas where the event and/or class is being conducted; (iv) the Competitive Rules; or (v) any other harm caused by an occurrence related to athletic and/or fitness
activities.

I HEREBY AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER. I HAVE READ THIS DOCUMENT, AGREE
TO AND ACCEPT THE TERMS, AND UNDERSTAND ITS CONTENTS.
I agree to the waiver.
Training Plan Compliance
I ACKNOWLEDGE THAT TRIATHLON, SWIMMING, CYCLING, MOUNTAIN BIKING, RUNNING, TREADMILL RUNNING, TRAIL RUNNING, STRENGTH TRAINING, BICYCLE FITTING, INDOOR CYCLING, FUNCTIONAL MOVEMENT SCREENING, AND GENERAL FITNESS ACTIVITIES ARE DEMANDING AND CARRIES WITH IT THE POTENTIONAL FOR DEATH, SERIOUS INJURY, AND PROPERTY LOSS. I HEREBY ASSUME THE RISKS OF PARTICIPATING IN THESE TRAINING PLANS, CAMPS, CLINICS, PRACTICES, WORKOUTS, PERFORMANCE TESTS, LABORATORY TESTS (Including metabolic, sweat, VO2, body fat, training zones, and lactate threshold testing). I certify that I am physically fit, and have not been advised otherwise by a qualified health professional.

I PLEDGE TO COMMUNICATE REGULARLY ABOUT MY HEATLH METRICS, AND COMPLETE WORKOUTS AS PRESCRIBED.
I agree to the training plan compliance.
Equipment Acknowledgement*
Carolina Multisports, LLC, (CM) will not be responsible or liable for damage or loss that may occur to our customers’ equipment while they are participating in any CM sponsored or supported event. This includes but is not limited to Triathlon training camps, handling skills camps, running or swimming or any other training or racing events and/or activities.

CM may provide transportation and/or housing of customer equipment. This includes but is not limited to items such as
bicycles, run/swim gear, electronics & any other related or personal equipment. DURING SUCH TRANSPORTATION OR
HOUSING. CM WILL NOT BE LIABLE FOR ANY DAMAGE OR LOSS DUE TO ANY CIRCUMSTANCES.
I agree to the equipment acknowledgement.
Photography and/or Video Release
Participants involved in any activities/consultation/classes/etc. offered by Joel Young and/or Carolina Multisports, LLC, may be photographed and/or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Carolina Multisports, LLC, website, or any editorial, promotional, social media, or advertising material produced and/or published by Carolina Multisports, LLC.
I agree to the photography and/or video release.
Anti-Doping Consent*
Please review the following webpage content and acknowledge:
I have reviewed the content below and agree to the anti-doping rules and regulations.
Athlete's Guide to Anti-Doping
Type full name for signature*
By typing my name, I confirm that I agree to the electronic submission of my this form and that I accept that the information provided constitutes a legally binding digital signature.

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Athlete Intake Questionnaire

Step 1 of 7 – Contact Information

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