Blind Runner Registration Form,, Use tab to go forward, shift tab to go back Blind Runner Registration Form,, Use tab to go forward, shift tab to go back
Personal Contact Info:

First Name,  required Last Name,  required Gender,  required M F

Birth Date m m/dd/y y,  required Visual Acuity,  required B1: NLP or LP only B2: 20/600 or worse B3: 20/200 to 20/600 B4: 20/199 to 20/70 Not Known

Email,  required If under 18, enter parent's email

Phone number   Phone type Home Cell Work Parent Other

If you are under 18 or still in High School, please list a parent as one of the phone contacts.
If under 18, Parent phone   Phone type Home Cell Work Parent Other

Street address   City,  required   State,  required   ZIP code

Support requested

Primary activity,   required fitness walking / hiking recreational jogging / running competitive running

Please describe your experience level with running / walking / track and field and the type of support you will want,
no more than 2 lines please
 

What is the average distance you will expect to run / walk any given day with your training partner? Miles not sure 0 2 or less 2 to 4 4 to 6 over 6

What is the longest training run or walk you expect to attempt in the near future? Miles not sure 0 2 or less 2 to 4 4 to 6 6 to 8 8 to 10 over 10

If you plan to run competitively, in what group would you compete? Group School Club Individual Other

If running competitively, what is your fastest expected race pace? minutes per mile, or P-R time in seconds if sprinter?, Distance
Distance 100 meters 200 meters 400 meters 800 meters 1 mile 5K 10K half marathon marathon   Minutes not sure 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15   Seconds not sure 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59

If you plan to run competitively for a school or a club, please enter the school or club name,

Name, Sport Season, Fall Winter Spring Summer Other

If you are not a school or club runner, please enter the following,

Is there a particular event you are training for like a marathon or other special race?    Yes    No
If yes, please enter, Event Name, Event Date,

Over what duration of time do you think you might want or need support? sport season listed above until event listed above a number of months a number of years indefinitely not sure

Possible training schedule
Please check all possible time slots that you would be available to train with an assigned guide or guides. We will use this info for schedule matching with prospective guides. Only 1 or 2 training sessions per week would be expected to actually be scheduled. Use spacebar to select desired checkboxes
Monday Morning Monday Afternoon Monday Evening
Tuesday Morning Tuesday Afternoon Tuesday Evening
WednesdayMorning Wednesday Afternoon Wednesday Evening
Thursday Morning Thursday Afternoon Thursday Evening
Friday Morning Friday Afternoon Friday Evening
Saturday Morning Saturday Afternoon Saturday Evening
Sunday Morning Sunday Afternoon Sunday Evening
Not sure of training schedule

Might you need help with transportation getting to and from workouts or events?     Yes Yes    No No

Personal statement:

Do you have a gender preference for any assigned guide runners?
Yes, Gender match with me Yes, definitely gender match with me
I prefer a gender match, but can compromise. I prefer gender match, but can compromise if need be
No, a gender match doesn't matter No, a gender match doesn't matter

If you have any particular needs or expectations for guide runners you could work with, please describe.
no more than two lines please


Do you have personal medical insurance?   Yes Press spacebar to say Yes, I have have personal medical insurance No Press spacebar to say No, I do not have personal medical insurance

What is the outcome you hope for from participation in this program? no more than four lines please
 

Please read the Running Blind's Athlete's Con'duct Pledge.
Press enter to go to Athlete's Con'duct Pledge,,

                                                Athlete's Conduct Pledge                                             

Are you willing to abide by the Con'duct Pledge? Yes Press spacebar to say Yes, I will abide by the con'duct pledge

Add any additional comments here, no more than four lines please