Susquehanna Striders Registration
First Name  
Middle Initial  
Last Name  
Address  
City  
State  
Zip  
Phone  
E Mail  
Birth Date  
Height  
Weight  
Do you currently exercise?  Yes  No  What types?  
If 'Yes', how many times a week?  One  Two  Three or more
Blood pressure (if known)   / 
Do you take blood pressure medication?  Yes  No
Has your doctor recommended walking for health reasons?  Yes  No
Where do you plan to walk? (check all that apply)  Outdoors  Mall  Treadmill
When do you plan to walk? (check all that apply)  Morning  Afternoon  Evening
Do you smoke or use tobacco products?  Yes  No
What is your most important health concern?  
Do you wish to receive exercise-related information via email?  Yes  No
May we publicly acknowledge your accomplishments in this program?  Yes  No
CONSENT AND RELEASE STATEMENT

By participating in Susquehanna Striders, I acknowledge that I am doing so willingly and I assume full responsibility for my actions. I hereby release and hold harmless The LifeCenter™, Susquehanna Health System, Lycoming Mall, the City of Williamsport and the Williamsport Merchants and Business Association from any and all liability for any injury or accident which might occur while walking on the walking courses or during examinations or tests that may be performed by Susquehanna Health System personnel during my participation in this program.

I AGREE  I DO NOT AGREE