Runner Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number with you during the SS200 *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Information *

First Name

Last Name

Phone number of Emergency Contact *

(###)

###

####

Have you ever smoked? *

No

Yes

If Yes, for more than 10 years

Do you drink alcohol? *

No

Yes - Less than 5 drinks per week

Yes - More than 5 drinks per week

Section 3 – Medical conditions we should know about *

None

Do you have any breathing problems such as Asthma, COPD (Emphysema or Bronchitis) Recurrent Infections or TBOption 2

Congenital Heart Disease

AF or other arrhythmia

Ischaemic Heart Disease or Angina or MI

Hyper or Hypotension

Do you have any conditions not lisetd?

Do you have any of the following Skeletal or Orthopedic Conditions that could affect your ability to complete the run? *

None

Osteoarthritis or Inflammatory Joint disease

Recent Fractures to any long bone or residual fracture

Recurrent severe joint pain, especially in hip, knees or ankles

Any Joint Replacement