STEP 1: Private Boot Camp Registration Form & Release

CONTACT INFORMATION
First and last name:
Address:
City:
State:
Zip:
Home phone:
Mobile phone:
E-mail address:
Confirm e-mail:
Emergency contact:    Phone:

PRIVATE CAMP DETAILS
Camp location:
Camp start date: None
Camp start time: (hh:mm am/pm)
Camp days
per week:
Is this your first camp?
Yes No, last camp attended:
How did you first hear about us? (Please be specific.)
Specifics:
Do you know anyone who would be interested in our boot camp program?
Name:
Phone:    Email address:

FITNESS BACKGROUND

I rate my current
fitness level as a:		 (1-10), 10 being high
My main goal is to:
Are you training for an event, such as a race, reunion, wedding, etc?
If so, what?
When?
Profession:
Date of birth:
Comments:

MEDICAL HISTORY

If you are returning and have no medical changes, the medical section below does not need to be completed. All agreements remain the same.

NOTICE: It is wise to seek your doctors 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 wear glasses or contact lenses? Yes
4. Do you have or have you ever had the following:
          Diabetes, adult or juvenile? Yes
          Asthma? Yes
          Anemia? Yes
          High blood pressure (hypertension)? Yes
          Seizure disorder (epilepsy)? Yes
          Heart disease?  Yes
          Lung disease?   Yes
          Kidney disease? Yes
          Liver disease?   Yes
5. Have you ever been knocked out? Describe:
6. Have you had a broken bone or fracture in the past 2 years? Describe:
     
7. Have you ever had a severe neck injury? Describe:
8. Have you ever injured your back? Describe:
9. Do you have back pain?   
10. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:
     
11. Do you have other physical conditions which cause pain? Describe:
     
12. Detail any surgical procedures:
     

RELEASE

This release is entered into between the undersigned and Austin Adventure Boot Camp. The purpose of Austin Adventure Boot Camp is to provide fitness instruction and coaching for various levels of athletes/individuals.

The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:

  1. Acknowledges that Stephanie McDonald and the Austin Adventure Boot Camp Coaches are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.

  2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Austin Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Austin Adventure Boot Camp 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/activities including the inherent dangers of the natural elements, 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 and Austin Adventure Boot Camp 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 Austin Adventure Boot Camp, nor anyone else has not 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.

Check the following:

I will remember to set my alarm and be at camp on time. Any violation will result in twenty push-ups per occurrence.
I agree that I will not consume alcohol during the month of Boot Camp. Any violation will result in twenty push-ups per occurrence.
I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence.
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. Any violation will result in twenty push-ups per occurrence.
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. By signing up for camp, I am making a commitment to myself. I am committed to a fit and healthy lifestyle. I understand that Austin Adventure Boot Camp will accept no excuses for my failure to fulfill my commitment to myself.

Your signature will be required at the time of your evaluation, and you agree to the terms now!

PAYMENT

NOTE: Your registration will be confirmed only after receipt of payment. Space is limited, so please submit your payment immediately.

Please select your payment method:

Using a coupon/gift certificate.* Amt/offer:  Gift cert no. (if available):
  Coupon/gift cert source:  Specifics:
  NOTE:  If paying online, the gift certificate amount will be manually refunded after completion of payment. Restrictions apply. Limit one promotional coupon/gift certificate per person. May NOT be combined with any other offer. Please submit your gift certificate to your coach on the first day of camp.
 
Paying online by credit card or e-check.
  Name* on account:
NOTE: *Name is required so that we can match your registration form to your payment. After submitting your registration form, you will be directed to the boot camp payment page where you must select the appropriate camp format. All e-check and credit card payments will be processed through PayPal. No PayPal account required.

NO PAPER PERSONAL CHECKS WILL BE ACCEPTED -- ONLY ONLINE E-CHECKS.

By submitting this form, you are agreeing to the terms above!