Women's Beginning Walking and Running Clinic

OFFICE USE ONLY: __ POS __ ActiveSalem __ Constant Contact

Women's Beginning Walking and Running Clinic - SPRING 2013

Select one group. Please print clearly.

___1. Leopard: (Beginning Walk Group - 5k goal) Walks safely, very slow pace
___2. Cougar: (Intermediate Walk Group - 5k goal) Moderate pace
___3. Jaguar: (Quick Walk Group - 5k/10k goal) Highly active, quick pace
___4. Panther: (1st Walk to Run Transition Group) Criteria: walk 30-45 minutes, 3-4 days/week for 8-12 weeks prior to the beginning of the clinic for a safer transition to running. Note: if you are out of shape and try to start running before you have been walking regularly for a few weeks, you will struggle.
___5. Cheetah: (2nd Walk to Run Transition Group) Currently runs some, active 3-5 days/week
___6. Bobcat: (Running Group - 5k/10k goal) Currently runs 3 or more days/week

** 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: (Please read before you sign.)
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 understand that audio headsets are not allowed and registration is non-refundable.

Enclosed:
___$100 Early Registration ___$110 after 2-19-13
___Alumni $90 Early Registration ___$100 after 2-19-13

Signature__________________________________ Date______________

Mail with check payable to GFR at:
Gallagher Fitness Resources, 135 Commercial St NE, Salem, OR 97301

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

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