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?

Event Running

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

Area of Body Injury:

Professional Training

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

Sources of Running / Walking Information

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

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

(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:

(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?

Over a million happy runners can't be wrong.

Write in your course City and Year
-- OR --
Write In Your Instructor's Name

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