Online_Registration

NOTICE: The following form is strictly for online registration purposes only. IF YOU ARE A RETURNING CAMPER, PLEASE DISREGARD THIS FORM AND PROCEED TO THE ONLINE SHOPPING CART. YOU CAN FIND THAT LINK ON THE MAIN REGISTRATION PAGE. This is a secure internet site. If you would like to download and fax or mail your registration and payment, please return to the main registration page to do so. Thank you.

Adventure Boot Camp Registration Form

X = Mandatory fields

First Name:X
Last Name:X
Address:X
Address 2:
City:X
State:
Zip:X
Job Title:X
Date of Birth:X	(mm/dd/yyyy)
Home Phone:X
Work Phone:
Cell Phone:
Email:X
Emergency Contact Name:X
Emergency Contact Phone:X
Camp:
I rate my current fitness level as (use scale of 1-10, 10 being highest = elite athlete):X
My main fitness goal is:X
My fitness goal in this camp is:
How did you hear about boot camp?:
If Referral please provide their name:
MEDICAL HISTORY QUESTIONAIRE:	All "YES" answers require a written explanation on the next page
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)?:
4. Do you have diabetes; Type I (IDDM) or Type II (NIDM)?:
5. Have you ever been found to be anemic (low blood count)?:
6. Do you have High Blood Pressure (hypertension)?:
7. Do you have or have you ever had Heart Disease?:
8. Do you have or have you ever had Lung Disease?:
9. Do you have or have you ever had Kidney Disease?:
10. Do you have or have you ever had Liver Disease?:
11. Do you have or have you ever had asthma?:
12. Do you have or have you ever had severe neck injury?:
13. Have you ever had been knocked out?:
14. Have you had a broken bone or fracture in the past 2 years?:
15. Do you wear glasses or contact lenses?:
16. Have you ever injured your back?:
17. Do you have back pain? If YES, highlight the best answer:
18. Have you had knee pain in the past 2 years that has disabled you for longer than a week?:
19. Do you have other physical conditions, which cause pain?:
20. Have you had any surgical procedures?:
21. Have you ver had your body fat tested?:
22. Are you training for a specific event?:
	If you are unsure about the definition of any terms in this form, please call us to clarify. Do not assume.
Explain all your yes answers here:
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE	Please reply to all questions below. If you answer yes to any of the questions below, talk with your doctor BEFORE you become more physcially active. Tell your doctor your intent to exercise and to which questions you answer yes. If you honestly answer no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. If your health changes so you then answer yes to any of the above questions, seek guidance from a physican.
1. Has a physician ever said you have a heart condition and you should only do physical activity reommended by a physician?:
2. When you do physical activity, have you had chest pain in the past month?:
3. When you were not doing physical activity, have you had chest pain in the past month?:
4. Do you ever lose consciousness or do you lose your balance because of dizziness?:
5. Do you have a joint or bone problem that may be made worse by a change in your physical activity?:
6. Is a physican currently prescribing medications for your blood pressure or heart condition?:
7. Are you pregnant?:
8. Do you have insulin dependent diabetes?:
9. Are you 69 years of age or older?:
10. Do you know of any other reason you should not exercise or increase your physical activity?:

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 and check each one.
	I agree that I will not consume alcohol during the month of Boot Camp.
	I agree not to use foul language during Boot Camp.
	I agree not to eat or say the words Twinkie, Donuts, Ho-Ho's, 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 arrive at camp ON TIME.
	I understand there is a 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. Camp fees cannot be used towards any other products or services provided by Premier Sports and Health.
	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.
INFORMED CONSENT, WAIVER, AND RELEASE AGREEMENT	This waiver and release is entered into between the undersigned and Washington DC Adventure Boot Camp/Premier Sports and Health, its instructors, officers, affiliates, and executors. The purpose of the Adventure Boot Camp Program offered by Premier Sports and Health is to provide fitness instruction and coaching for various levels of athletes/individuals. The undersigned hereby acknowledges 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 Adventure Boot Camp does not guarantee neither good nor bad will occur, nor guarantees the training advice given by 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, marital 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.
5.	By checking below I expressly waive, release, discharge and agree not to sue from any liability of dealth, disability, personal injury, or action of any kind Adventure Boot Camp, Premier Sports and Health, its instructors, officers, affiliates, and executors for the undersigned participating in said sporting events and/or training for said sporting events.
6.	By checking below I agree that this is the full agreement between the parties, that no representatives of Washington DC Adventure Boot Camp or Premier Sports and Health or 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.
	By checking here, I agree to all of the terms and conditions of the Adventure Boot Camp