Participant Information * First Name Last Name Date of Birth MM DD YYYY Email Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Previous Running/Walking Experience Please describe any previous experience you have with walking, running, or participating in similar events. Emergency Contact Information Emergency Contact Information * First Name Last Name Emergency Contact Email Emergency Contact Phone Number * (###) ### #### Relationship to Participant Doctors Information Doctors Name Doctors Phone Number Medical Information * Do you have any medical conditions or injuries we should be aware of? Yes No If yes, please specify: Do you carry an EpiPen? * Yes No Additional Information How Did You Hear About Us? Flyer Friend Online Social Media Would you like to receive updates about future programs? Yes No Terms & Agreement Term & Agreement * I affirm that the health information provided is accurate to the best of my knowledge. I acknowledge the physical nature of the run clinic and have consulted with a healthcare provider, when necessary, prior to participating. I release AdaptDaily Wellness from any liability for injury or harm that may occur as a result of my participation. Agree Date Signed * MM DD YYYY Digital Consent * Please type first and last name and click checkbox for digital consent First Name Last Name By checking this box, I agree to the terms and conditions outlined for participation in the 10k Walk To Run Clinic and confirm that the information provided is accurate to the best of my knowledge. I agree to the Terms and Conditions and confirm that all information provided is true and accurate. Thank you! 10k Walk To Run Clinic Registration FormZero to 10K (13 Week) Walk to Run Clinic
