Online Registration Form


PRINTED REGISTRATION FORM

 

1. Print this form; fill in your information clearly and completely, and sign the release.

2. Choose camp options and payment option.

3. Choose the method to return your forms:

                              Bring with you to your evaluation, or

By Mail:     560 N. Bullard Ave,
Suite 53/54 Goodyear 85338

You may pay by check to Goodyear Adventure Fitness Boot Camp, or Pay Online.

We use PayPal for your safety and convenience.

 

I am signing up for camp beginning on: _________________

Located at: Goodyear Community Park, 3151 N. Litchfield Rd. (just north of Thomas Rd.). MAP

My Name: ________________________________________

Date of birth (required): ______ / ______ / ______

Address: ________________________________________________________________

Street City State/Zip

Home Phone: ___________________________ Cell Phone: ______________________

Job Title: ________________________________Work Phone: ____________________

Email:_________________________________________________________________

Emergency Contact Name: ______________________  Phone #: _______________________

I rate my current fitness level as a_____________ (use scale of 1-10, 10 being highest = elite athlete)

My fitness main goal is: ______________________________________________________________________

My fitness goal in this camp is: ________________________________________________________________

How did you hear about boot camp? ____________________________________________________________

If by Referral please provide their name: ______________________________________________

Payment Options (check one)

                        Check or money order is enclosed
                             (made out to Goodyear Adventure Fitness Boot Camp)

                        I paid online

Attendance Options (check one):

                        5 days per week ($299)
                        3 days per week ($199)

MEDICAL HISTORY QUESTIONNAIRE

All "YES" answers require a written explanation on the next page
 

Question

YES NO
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, circle the best answer below.

Almost Never    Seldom    Occasionally    Frequently    with vigorous exercise or heavy lifting

    
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 ever 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.

What are your goals for the next three months? ___________________________________
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PLEASE EXPLAIN ALL "YES" ANSWERS BELOW. PLEASE REFERENCE THE QUESTION NUMBER.

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NOTICE:

It is wise to seek your doctor’s advice BEFORE beginning any health/fitness/nutrition program!

Informed Consent, Waiver, and Release Agreement

This waiver and release is entered into between the undersigned and Goodyear Adventure Boot Camp its instructors, officers, affiliates, and executors.

The purpose of the Adventure Boot Camp Program offered by Goodyear Adventure Boot Camp 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 Goodyear Adventure Boot Camp does not guarantee neither good nor bad will occur, nor guarantees the training advice given by Goodyear 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 Goodyear 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 Goodyear Adventure Boot Camp or _________ 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.

PERFORMANCE PLEDGE

In the spirit of harnessing your best effort and providing optimum results from your Goodyear Boot Camp experience, we have established the following policies to which you will need to adhere. Please read and initial 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.

(Any violation of the above statements will result in twenty push-ups per occurrence.)

I understand that photos or video may be taken during the course of my involvement in Goodyear 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. Camp fees cannot be used towards any other products or services provided by Goodyear Adventure Boot Camp.

 

__________________________________ ________________________________ _____ / _____ / _____
 Signature                                                      Printed Name                                           Date