Adventure Boot Camp Registration Form

Name:______________________________________

Street:______________________________________

City:_______________________________________ Province:______Postal Code:_______________

Profession: _________________________________

Date of Birth ___/___/___ Emergency Contact and phone number______________________________________________________

Home Phone (_____)____________________ Work Phone (_____)_____________________
Fax Number (___)_______________________
E-mail _________________@_____________
I rate my current fitness level as a _____ (1-10), ten being high.
I was referred by ______________________________.
My main goal is to ____________________________________________________________________.
Payments can be made by cash or cheque

Please check off packages you are interested in
Option #1 - 3 times per week plan for $149.00 (Boot Camp, without nutritional counseling) ______
Option #2 - 5 days per week plan for $249.00 (Boot Camp without nutritional counseling) ______

Packages exist for clients wishing to make a long term commitment to Boot Camp. Package deals do reduce the monthly fee substantially. Please call for details.

Confirmations and detailed instructions will be mailed prior to the start of Camp. Waiver must be signed prior to participation.

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 Adult or Juvenile? Yes No

5. Have you ever been found to be anemic (low blood count)? Yes No

6. Do you have High Blood Pressure (hypertension)? Yes No

7. Do you have or have you ever had the following diseases?

8. Do you have asthma? Yes No

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?

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:

18. What are your goals for the next three months?

19. Have you had your body fat tested? If yes, what percent is it?

20. Are you training for a specific event? If yes, explain:

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

RELEASE

This release is entered into between the undersigned and Okanagan Adventure Boot Camp/ Kelly Hanscom, its officers, affiliates, and executors in addition to the City of Vernon, Polson Park and recreation director Al McNiven.The purpose of Okanagan Adventure Boot Camp / Kelly Hanscom 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 Kelly Hanscom is not a physician and is 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 Okanagan Adventure Boot Camp / Kelly Hanscom does not guarantee neither good nor bad will occur nor guarantees the training advice given by Okanagan Adventure Boot Camp / Kelly Hanscom, 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, 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 Okanagan Adventure Boot Camp / Kelly Hanscom 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 Kelly Hanscom 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.

Initial the following:
___ I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of 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, but I can receive a credit (for unused portion of camp) towards a future camp if I'm not able to complete the one I originally joined. Camp fees cannot be used towards any other products or services provided by Kelly Hanscom unless discussed with Kelly Hanscom
___ I will remember to set my alarm and be at camp ON TIME.

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Signature

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Printed Name

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Date