Name: ________________________________________________________________________

Address: _______________________________________________________________________

City: _____________________________________ State: _______  Zip Code: ________________ 

Date of Birth ____________________    Height: ____________  Weight: _____________

Area Code: ______   Phone #: ____________________________________________

100m time_____  :  _____

400m time _____  :  _____

Personal Best: ____  '   _____"

 

Weightlifting Questions

Are you currently under the care of a physician?

 Yes No
Do you currently have any medical or other condition that would prevent you from engaging in a regular weightlifting program? 
Yes No
Do you have now or are you recovering from any injuries that would make weightlifting difficult or impossible?
Yes No
Have you ever lifted weights before?
Yes No
If yes, give a brief description of what kind of weightlifting workouts you have done in the past.
Do you know how to do "cleans"?
Yes No
If yes, what amount of weight do you believe yourself capable of lifting?
Yes No
Do you know how to do "jerks"?
Yes No
If yes, what amount of weight do you believe yourself capable of lifting?
 
Do you know how to do "snatches"?
Yes No
If yes, what amount of weight do you believe yourself capable of lifting?
 
Do you know how to do squats?
Yes No
If yes, what amount of weight do you believe yourself capable of lifting?
 
Do you have access to a "squat rack" where you lift?
Yes No
If no, can you change your current weightlifting situation?
Yes No
Do you have someone where you lift who can provide instruction?
Yes No
Do you have someone with whom you can do your weightlifting?
Yes No


Running Questions

Do you currently have any medical or other condition that would prevent you from engaging in a regular running program?
 Yes No
Do you have now or are you recovering from any injuries that would make running difficult or impossible?
 Yes No

Do you own a pair of running spikes?

Yes No
Ideally, a pair of "interval" spikes or long jump shoes is what you should use or purchase

Do you have access to a synthetic running track?

 Yes No

Do you have access to an indoor facility or fieldhouse for doing running workouts during the winter months?
  

Yes No

 

Jumping Questions

Do you currently have any medical or other condition that would prevent you from engaging in a regular jumping program?  
Yes No
Do you have now or are you recovering from any injuries that would make jumping difficult or impossible?  
Yes No
Do you own a pair of triple jump specific shoes?
 Yes No
If no, would you like a suggestion on what kind of shoes to purchase?  
Yes No
Do you own a video camera? Yes No
Is your track and/or field coach flexible about jumping days? 
Yes No

If no, can something be done about it? Parents? AD?  

Yes No
On what days of the week do you normally have meets?


General Questions

Do you compete in other track and field events?
 Yes No
If yes, please list the other events in which you compete.
Do you compete in other organized sports at your institution?  
Yes No
If yes, please list the other sports in which you compete.
Do you wish to start this program for the winter season?
Yes No
Do you anticipate any conflicts arising between yourself and the coaching staff at your institution that will make it overly difficult for you to take part in this personalized program? 
Yes No
If yes, please explain the potential problems in detail. If yes, do you believe there are solutions to these potential problems?  
Yes No
If yes, please explain these solutions in detail


Disclaimer

The lack of cooperation of the coaching staff at your institution is not a reason for a request for a refund of the money’s paid for the Interactive Coaching. Occasionally, problems arise when coaches discover their athletes are seeking alternate methods to those espoused by said coaching staff in order to maximize their athletic potential in different track and field events. This is a problem that rests squarely with the individual athlete. It is up to the athlete and/or his/her family to make whatever accommodations necessary to be able to implement the program. We will now ask that you indicate your intention to go forward with the Interactive Coaching program. By doing so you acknowledge that you are in good health and physically able to execute the program as written. You acknowledge that no refunds will be issued in the case that you become physically incapable of executing the program due to injury or because the coaching staff at your institution insists that you do only their training regimen or in some way makes it difficult or impossible for you to implement the program.

 

Parental Consent/Participation Waiver

I hereby grant permission for my child to participate in the Triple Jump Central program. I verify that my child has had a physical exam in the past year and is able to participate in the activities related to the training. I agree to indemnify, hold harmless and defend Mike Lariza, Triple Jump Central, and Bravo Web Solutions (webmaster), their agents or employees from any and all liability for injury to my child, as well as any injury or damage caused by my child.

 

Student Signature:  _____________________________________ Date:___________.
(must be 18 or older)

 

Parent or GuardianSignature:  _____________________________________ Date:___________.
(if student is under 18)

By acknowledging the above you are accepted into the Interactive Coaching program when payment is received (via Paypal or enclose your check or money order with this form) for the first season that you request a training program be designed on your behalf. Please print this questionnaire with your signature affixed, or the signature of a parent or legal guardian if you are under the age of legal consent, and mail to: