Questionnaire Coaching One on One
Please complete the questionnaire below for Coaching Services start-up. Thanks! Simon Says Cycling
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First and Last Name
Email
Telephone
What's your age?
Height
Weight
Goal Weight
What Level Coaching Service do you want to sign-up at?
Preferred Payment Method:
Do you have a TrainingPeaks account?
How many hours can you train consistently each week (be realistic)?
How many years have you been cycling?
Do your compete in races (indicate category)?
Do you train with a power meter and heart rate monitor?
Whats your maximum heart rate (last year) or threshold heart rate?
Whats your current threshold power (40km TT power or 93-95% of best 20 minute power)?
Whats your current best 4-5 minute power (last 6 months)?
Whats your current best 1 minute power (last 6 months)?
Whats your current best 5 sec power (last 6 months)?
What are your cycling strengths?
What are your improvement goals physically?
What are your improvement goals related to bike handling, skill and strategy?
What are your improvement goals related to to the mental side like confidence, discipline, fears, habits etc.?
What are your improvement goals related to your weight and diet?
Is there a race goal or event goal/trip we are working towards (please list dates)?
What is your ultimate cycling goal?
Any health issues or injuries that affect you?
Are you cleared by a doctor for strenuous exercise?
Please describe in detail what a typical training week looks like for you with the days your train, the hours, and the type of training:
Please list race dates, event dates, travel etc. that should be included in your training for the next 2-4 weeks:
When would you like to start with coaching (date)?
What day and time works for a start-up consultation over the phone/Zoom (please provide 2-3 options).
RELEASE OF LIABILITY  (please read)                                                                                             I am fully aware that participating in any exercise program can be a potentially dangerous, hazardous activity. I am specifically aware of the potential dangers of participating in the Simon Says Cycling, LLC training programs, plans, and/or events. In consideration of my acceptance into the Simon Says Cycling, LLC training program, plan, and/or events, I, the undersigned (parent or guardian if participant is under 18 years of age) intending to be legally bound, do hereby for myself, my heirs, executors, administrators, and assigns, assume any and all risks of participating in said training programs, plans, and events, and I hereby waive and release any and all rights and claims for damages I my have against Simon Says Cycling, LLC, its representatives, successors, and assigns for any and all injuries, all such risks being known and appreciated by me. I hereby waive and release the above entities, their representatives, employees, successors, and assigns from any and all claims or liabilities of any kind arising out of my participation in said training programs, plans, and/or events, even though these claims and liabilities might arise out of the negligence or carelessness on the part of the persons named above. I attest and verify that I am physically fit and prepared for the Simon Says Cycling, LLC training programs, plans, and/or events, and that a licensed medical doctor has verified my physical condition within the last six months. I hereby assume full responsibility from any injury, including my death occurring while participating in, or as a result of, my participating in the Simon Says Cycling, LLC training programs, plans, and/or events, and hereby release, waive, discharge and covenant not to sue Simon Says Cycling, LLC and its successors, representatives, employees, assigns, or other participants in the Simon Says Cycling, LLC training programs, plans, and/or events from any and all liability to me, my personal representatives, heirs, successors, and assigns for any loss or damage and claim or demands therefore on account of injury to me, including my death, whether caused by their negligence or carelessness in advising me while participating in the Simon Says Cycling, LLC training programs, plans, and/or events. *
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