Kicks Back

Patient Name*

First NameLast Name

Date of Birth (Please Note: This program is open for people with CF who are 6 years old or older)*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

Age*

Gender*

CF Care Center*

CF Physician*

Favorite Color*

What are your current exercise habits?*

Do you have any exercise goals?*

Would you be interested in providing a picture of you (or your child with CF and you) for the Rock CF Foundation's website and social media outlets? (Please note: only first name will be used)*

YesNo

Please Choose:*

MensLadiesYouth

Shoe Size*

Please Choose:*

NeutralStabilityNot sure

As part of the Kicks Back program, the Rock CF Foundation would like to offer you a free race registration to a running of your choice. It can be a 5K, 10K, Half Marathon, Marathon, or any other distance! If and when you are ready to participate please email Emily@letsrockcf.org to get set up!

Rock CF Foundation has partnered with the Attain Health for CF specific virtual strength coaching. The EmPower program offers a functional movement assessment to develop an individualized exercise program that is delivered through an app. This program is available for a small monthly fee, scholarships are also available. Would you like more information regarding this program?

YesNo

Waiver for participation: I hereby release and hold harmless of myself, mychild, and/or representatives of the Rock CF Foundation, RunDetroit, and anysponsors. By signing this I agree that I am running/walking under my own will and under the guidance of my physician. I understand that I am responsible for medical coverage for me and/or my child. Requires Patient/GuardianSignature *

Once your application is submitted, please allow 2-4 weeks for us to review your application and to ship your new kicks!

Shoe Specifics