Women's Beginning Walking and Running Clinic

Women's Beginning Walking and Running Clinic - Fall 2008

OFFICE USE ONLY: __ POS __ ActiveSalem __ Constant Contact __ Survey __ Forum __ T-shirt

Please check the group (only one) that fits you the best for now. Remember that you can change groups at any time.

___1. Leopard: (Beginning Walk Group)
___2. Cougar: (Intermediate Walk Group)
___3. Jaguar: (Quick Walk Group)
___4. Panther: (1st Walk to Run Transition Group)
___5. Cheetah: (2nd Walk to Run Transition Group)
___6. Bobcat: (Running Group)

** Please Print Clearly **

Name_________________________________________________

Address_______________________________________________

City__________________________ State_____ Zip___________

Phone__________________

Emergency Contact Phone__________________

Birthday M___ D___ Y___ (Required for Heart Rate calculations) Age____

E-mail________________________________________________
Required for Women's Clinic Updates and On-Line workouts

WAIVER:
I know that running/walking is a potentially hazardous activity. I should not enter a beginning run/walk program unless I am medically able and have consulted with my physician. I acknowledge the effects of weather, including cold, windy conditions, rain, high heat and/or humidity, or that falls, contact with other participants, the condition of sidewalks and/or roads, and traffic on the route are all risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of my being accepted into the beginning run/walk program, I, for myself and anyone entitled to act on my behalf, waive and release Gallagher Fitness Resources, the City of Salem, and all other sponsors, program officials, their representatives and successors from all claims or liabilities of any kind arising out of my participation in these activities even though that liability may arise out of negligence on the persons named in this waiver. I grant permission to Gallagher Fitness Resources to use any photographs, motion pictures, video recordings, or any other record of this clinic for any legitimate purpose. I also understand that registration is non-refundable once it has been received.

Enclosed:
___$80 Early Registration ___$100 after 7-21-08
___Alumni $65 Early Registration ___$85 after 7-21-08
T-shirt: $10 (Limited sizes available. Please check in the store.)
Total: $______

Signature__________________________________ Date______________

QUESTIONS Call 503-364-4198 or e-mail: Susan@ActiveSalem.com

Site by AbleDesign