E-mail:

Phone Number:

Gender:
Male Female

Age:

Are you a Lexington Medical Center employee?
Yes
No

Would you like to receive weekly text message tips?
to opt-in, text "RUN" to 30364
Yes.
No.

Are you participating in the program as part of another group?
Yes.
No.

Will this be your first 5K (walking or running)?
Yes.
No.

Are you currently physically active for at least 30 minutes a day, most days of the week?
Yes.
No.

What level exerciser do you consider yourself?
Beginner Intermediate Advanced

Please read consent form below.   By submitting this form, I hereby acknowledge and agree as follows: I hereby consent to voluntarily engage in the WACH FOX, Health Directions - Lexington Medical Center and Strictly Running GET FIT/STAY FIT Virtual 5K, as outlined in this document. I agree to abide by the rules and policies of WACH FOX and Health Directions – Lexington Medical Center. I also understand that if I have a problem or question about any rule or policy that I should contact WACH FOX or Health Directions directly. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, or other illness that would prevent my participation unless otherwise stated. I hereby expressly assume all of the risks, known or unknown, which could occur through my participation in the WACH FOX and Health Directions – Lexington Medical Center and Strictly Running GET FIT/STAY FIT Virtual 5K. I assume full responsibility during and after my participation for my choices to use or apply, at my own risk, any portion of the information or instruction I receive, or any Health Directions – Lexington Medical Center or Strictly Running training program. It is my understanding and I have been informed, that there exists the remote possibility during exercise and fitness testing of adverse changes including abnormal blood pressure, fainting, disorders of heart rhythm, and very rare instances of heart attack, stroke or even death. I understand that no claim is made by WACH FOX, Health Directions – Lexington Medical Center and Strictly Running regarding assessment and treatment of any mental or physical disease or condition and that no physician will be present. I understand that if I experience symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences, I agree to decrease or stop exercise and inform a professional of my symptoms. I have been informed that the information that is obtained in this training program/registration process will be treated as confidential information and will consequently not be released or revealed to any person without my expressed written consent. I do hereby release, and forever discharge WACH FOX, Health Directions - Lexington Medical Center and Strictly Running and the aforementioned directors, administrators, employees and all others acting on their behalf, from any and all responsibility or liability from injury or damage as a result of my participation in the GET FIT/STAY FIT Virtual 5K. Despite the fact that a complete accounting of all risks is not possible, I am satisfied with the review of the risks that was provided to me and it is still my desire to participate. I acknowledge that I have read this document in its entirety and or that it has been read to me if I was unable to do so. I consent and agree to all services and procedures as explained in this document.