Name:

Date of Birth:

Age:

Address:

City:

State:

Zip:

Home Phone

Cell Phone

Email:

Personal Physician's Name:

Address:

City:

State:

Zip:

Emergency Contact:

Relationship:

Day Phone:

Evening Phone:

Please list any medication taken on a regular basis (prescription and non prescription):

Medication / Dose / Frequency / Reason
1.

2.

3.

4.

5.

Allergic To:

Reaction:

Please list any current illness, recent surgeries, or past medical problems or surgery of note:

Heart Disease Heart Attack Heart Surgery Heart Murmur

Hypertension Thyroid Problems Asthma Wheezing

Diabetes Epilepsy Anemia Stress Fracture

Swim:

Yards per week:

Sessions per week:

Hours per week:

Bike:

Yards per week:

Sessions per week:

Hours per week:

Run:

Yards per week:

Sessions per week:

Hours per week:

Weight Training:
How many sessions per week?

Cross Training:
What activities do you do?

How many sessions per week?

Are you a member of the Wildcat Masters Swim Team? Are you a member of the Bluegrass Triathlon Club? Are you a member of the Bluegrass Cycling Club? Are you a member of the Todd’s Road Stumblers?

NO NO NO NO

YES YES YES YES

Please list each race as an “A” race or a “B” race”