Medical Information Form CrazYman 2017

Emergency Contact and Medical Information – CrazYman Training Challenge – 2017
									M	F
Name				Date of Birth					Sex
Cell Phone		Home Phone		Work Phone				Other
Address				Address
City, ST, ZIP Code				City, ST, ZIP Code
Alternative Emergency Contacts
Primary Emergency Contact				Secondary Emergency Contact
Home Phone		Work Phone		Home Phone				Work Phone
Address				Address
City, ST, ZIP Code				City, ST, ZIP Code
Medical Information
Hospital/Clinic Preference
Physician’s Name						Phone Number
Insurance Company						Policy Number
Special Health Considerations;
Allergies
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for me and waive my right to informed consent of treatment if incapacitated. This waiver applies if an authorized contact cannot be reached in the case of an emergency.
Signature						Date
I release Slade Coaching and individuals Linda Slade and Henry “Skip” Slade from liability in case of accident or health issues that occur during this training event related to Slade Coaching and CrazYman Training Challenge, as long as normal safety procedures have been followed.
Signature						Date
Witness Signature						Date

NOTE: This form will be shredded when it is no longer needed. It will ONLY be used in connection with CrazYman training events. If you prefer to take possession after the event, just ask.

CrazYman Duathlon Training Event - 29 January 2017 - 10:15

Are you looking for a reason to start training, or a new or different challenge, or a way to test yourself to see what you're capable of, or something more like an original, old-school “event” in a relaxed, supportive environment with friends, that's beginner friendly, and has no crazy entry fee? Here’s your chance!!!

1 ~~ Duathlon format training event at Mission Bay/Fiesta Island: Run 1 mile, Ride 3 loops Fiesta (12.5 miles), Run 5K/3.15 miles

2 ~~ Tire Changing Clinic and Practice

3 ~~ Post-race no-host lunch - Breugger's? Off Shore Tavern? Rubio's?

This is intended to be a training opportunity. It is NOT A RACE. There are NO awards, t-shirts, prizes, swag bags, timing chips, or race bibs. There will be a record board for those who want to record their training split times.

Come out and train. See what members of the "CrazyTrain" are like. Be inspired. Test yourself. See what's possible. Have fun!

This is a training event, not a race. Races require permits. Therefore space is limited due to city group regulations.

The start time is 10:15 to avoid conflict with a scheduled 5K in the area. The starting location will depend on the condition of the dirt parking lot at the entrance to Fiesta Island.

More information will be posted but please go to the Facebook event page and click "going" if you are actually planning to go. Invite a friend.