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Personal Information

First Name		Last Name
E-mail Address
Street		City
State		Zip Code
Country		Phone
Birthday
Sex	Female Male
Education	High School College Post Graduate Degree
Field of Study

Teaching and Presentation Skills

(Check all that Apply)
I currently present and demonstrate materials about fitness and health to individuals on a ongoing basis:
I currently present materials about fitness and health to groups on an ongoing basis:
I have presented to groups and individuals in the past:
I have never presented materials about fitness and health:
I regularly do public speaking, teaching and presentations:
I have done little public speaking, teaching or presenting:

Goals of the Training Workshop

Please write 250-500 words that describes why you want to become a ChiRunning & ChiWalking Instructor:

Please tell us which training location/date you'd like to attend.

Anything Else You Want to Tell Us Tell us anything about yourself that has not been covered but that you feel you would like us to know:

ChiRunning & ChiWalking Experience

(Check all that Apply)
Read Book		ChiRunning	ChiWalking
Viewed DVD		ChiRunning	ChiWalking
Audio CD		ChiRunning	ChiWalking
One-on-One Instruction		Number of Hours
1 Day Workshop		Half Day Workshop
Length of Time Practicing ChiRunning / ChiWalking:		Months	Years
To what extent do you feel you've learned the techniques?

Fitness Experience

Do you have a regular fitness program?

Number of Years

Number of Days Per Week:

Number of Miles Per Week

Average Training Pace Per Mile:

What terrain do you run on?

(Check all that Apply)
Road		Trail
Dirt Roads		Hills
Track		Treadmills

Event Running

Have you run in an event?
If YES please fill in below:
5K:		Number of Times:
10K:		Number of Times:
Half Marathon:		Number of Times:
Marathon:		Number of Times:

What is the frequency of running/walking injuries in the last 2 years:

Area of Body Injury:

(Check all that Apply)
	Upper Leg/Hip		Neck/Head		Knee
	Below Knee		Back

Professional Training

Have you had any professional sports training?
If YES please describe:

Sources of Running / Walking Information

(Check all that Apply)
Magazines		Websites
Newsletters		Books
Friends		Other
Other Sources

Other Physical Fitness Certifications/Qualifications

(Check All that Apply)
AFAA		ACE
NASCM		Personal Trainer
Yoga Instuctor		Pilates Instructor
Spinning Instructor		T'ai Chi Instructor
Group Trainer		Other
Other Martial Arts Instructor
I have Personal Trainer Insurance:
I have Red Cross CPR Certification:
(this will be required for Certification)

Other Sports You Participate In

Pick 5 for most time spent, pick 1 for least time spent.
Running
Walking
Swimming
Bicycling
Other

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