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OFFICE USE ONLY: __ POS __ ActiveSalem __ Constant Contact
Women's Beginning Walking and Running Clinic - FALL 2010
Please select one group.
___1. Leopard: (Beginning Walk Group - 5k goal) Walks safely, slow pace
___2. Cougar: (Intermediate Walk Group - 5k goal) Moderate pace
___3. Jaguar: (Quick Walk Group - 5k/10k goal) Quick pace, highly active
___4. Panther: (1st Walk-to-Run - 5k goal) Criteria: walk 30-45 minutes, 3-4 days/week for 8-12 weeks prior to August 3rd to ensure a safe and enjoyable transition to running.
___5. Cheetah: (2nd Walk-to-Run - 5k goal) Currently runs some, active 3-5 days/week
___6. Bobcat: (Run - 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:
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:
___$90 Early Registration ___$100 after 7-20-10
___Alumni $80 Early Registration ___$90 after 7-20-10
Signature__________________________________ Date______________
QUESTIONS Call 503-364-4198 or e-mail: Susan@ActiveSalem.com
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