Register - Team Atomica

Please fill in the following form as completely as possible below. This information is confidential to Team Atomica and will not be shared with anyone.

Member information

Email Address *

Please create a password *

First Name *

Last Name *

Postal Code *

Mobile Phone

Other phone

Insurance affiliation & number if applicable (MSO, OCA, OAT, OA):

Athletic History

Sports currently practiced:

Level of participation:

Are you on a strength program?

Current injuries:

Past injuries/surgeries:

Swimming History

# of years swimming

Current best 400m effort (estimate if necessary)

Best ever 400m effort

Running History

# of years running

Current best (estimate if necessary)

Best 10k time/estimate ever

Cycling History

Experience Level

Current best (estimate if necessary)

Best ever

Emergency Contact

First Name *

Last Name *

Postal Code *

Mobile Phone

Other phone

Medical Information

Allergies

Medical Conditions

Medications

Past incidents?

Additional information

Please describe any additional information below

I HEREBY AFFIRM THAT I AM EIGHTEEN, I HAVE READ THIS AGREEMENT, I UNDERSTAND ITS CONTENT, AND INTENTIONALLY AND VOLUNTARILY SIGN THIS AGREEMENT *

I agree

Please sign below *

Today's date *