| REGISTRATION INFORMATION: |
| Full Name: * | |
| E-mail Address: * | |
| Address: * |
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| City: *
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| Zip: * | |
| Date of Birth: * |
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| Emergency Contact & Phone * | |
| Your Home Phone: * |
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| Your Work Phone: |
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| Fax: |
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| Your Job Description? * | |
| Program Type: * | |
| Camp Start Date and Time: * |
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| Is this your first camp? * | Yes
No |
| If you answered no above, when was the last camp you attended? | |
| How did you find out about Mesa Boot Camp? | |
| I rate my current fitness level as a: * | |
| What are your goals for the next three months? | |
MEDICAL HISTORY
PLEASE NOTE: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program! |
| 1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? | |
| 2. Do you take any prescribed medication on a permanent or semi-permanent basis? | |
| 3. Do you have a seizure disorder (epilepsy)? | Yes
No |
| 4. Do you have diabetes? If Yes, list medications: | |
| 5. Have you ever been found to be anemic (low blood count)? | Yes
No |
| 6. Do you have High Blood Pressure (hypertension)? (List medications if applicable:) | |
| 7. Do you have or have you ever had any of the following diseases: Heart Disease, Lung Disease, Liver Disease, Kidney Disease. (If yes to any please specify) | |
| 8. Do you have asthma? (List medications if applicable) | |
| 9. Have you ever had a severe neck injury? Describe: | |
| 10. Have you ever been knocked out? Describe: | |
| 11. Do you wear glasses or contact lenses? | Yes
No |
| 12. Have you had a broken bone or fracture in the past 2 years? Describe: | |
| 13. Have you ever injured your back? Describe: | |
| 14. Do you have back pain? | Never
Seldom
Occasionally
Frequently with vigorous exercise or heavy lifting |
| 15. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe: | |
| 16. Do you have other physical conditions which cause pain? Describe: | |
| 17. Detail any surgical procedures: | |
RELEASE
This waiver and release is entered into between the undersigned and Mesa Adventure Boot Camp, its instructors, officers,
affiliates, subsidiaries and executors.
The purpose of the Mesa Adventure Boot Camp Program offered by Nicole Harper, is to provide fitness instruction and coaching
for various levels of individuals/athletes.
The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:
1. Acknowledges that the instructor is not a physician and is not trained in any way to provide medical diagnosis or any other
type of medical advice.
2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but Mesa Adventure Boot Camp does not guarantee neither good nor bad will occur, nor guarantees the training advice given by Mesa Adventure Boot Camp or its instructors will produce good nor bad results.
3. Acknowledges that the undersigned has been told if they feel tired, feel pain or feel out of the ordinary in any way either
related to your training, or otherwise, that the undersigned should contact a physician at once.
4. Acknowledges that boot camps, aerobic classes, martial arts, kick boxing, running, kung-fu, weight training, obstacle courses, and any other related sports are an extreme test of one's mental and physical limits and carry with it potential for damage or loss of property, serious injury and death. That the undersigned assumes the risks of participating in these types of events and activities, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop.
The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Mesa Adventure Boot Camp, its instructors, officers, affiliates, and executors for the undersigned participating in said sporting events and/or training for said sporting events.
The undersigned agrees that this is the full agreement between the parties, that no representatives of Mesa Adventure Boot Camp nor anyone else has verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.
The undersigned agrees to confidentiality with respect to Mesa Adventure Boot Camp and all services provided by same. Undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of Mesa Adventure Boot Camp. The undersigned agrees to non-compete within a 50 mile radius of Mesa Adventure Boot Camp for a period of 5 years from date of participation.
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| By clicking this checkbox, I signify that I have read and agree with all the above
RELEASE text. * |
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PERFORMANCE PLEDGE
In the spirit of harnessing your best effort and providing optimum results from your Boot Camp experience, we have established the
following policies to which you will need to adhere.
Please read, then agree to each of the following by entering a checkmark in the box:
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| I agree that I will not consume alcohol or eat fast food during the month of Boot Camp. * | |
| I understand that diet and nutrition will affect my fitness goals and performance during Boot Camp. * | |
| I agree not to use foul language during Boot Camp. * | |
| I agree not to eat or say the words Twinkie, Donuts, Ho-Hos, Ding Dong, or Cup Cake during the course of Boot Camp. * | |
| I agree to show up for Boot Camp every day unless it is an excused absence from my doctor or pre-approved with Boot Camp directors. * | |
| I will remember to set my alarm and arrive at camp ON TIME. * | |
(Any violation of the above PERFORMANCE PLEDGE statements will result in twenty push-ups per occurrence.)
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| I understand that photos or video may be taken during the course of my involvement in Boot Camp, which may be used for promotional purposes. I understand that my before & after photos will not be used for any promotional purposes unless I give written authorization. * | |
| I understand there is no refund policy, but I can receive a credit (for unused portion of camp) towards a future camp if, for reasons beyond my control, I am not able to complete the one I originally joined. THE CREDIT MUST BE USED WITHIN 90 DAYS OF ORIGINAL SIGN UP DATE. Camp fees cannot be used towards any other products or services provided by Mesa/Gilbert Adventure Boot Camp. * | |
| I will bring a positive attitude and expect to have FUN! * | |
| By clicking this checkbox, I signify that I have read and agree to all Terms and Conditions listed above. * | |
| By entering your name here, you signify that you are affixing your signature electronically to this form. * | |
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| * Required | |
