Online Registration Form for Goodyear Adventure Boot Camp

For a Printable Registration Form: Click Here

I am signing up for the camp:

Date:

For this time slot:

5:00-6:00 AM (5-Day Camp)

5:00-6:00 AM
(3-Day Camp Mon, Wed, Fri)

6:30-7:30 PM
(3-Day Camp Mon, Wed, Thurs)

Fitness Blast Only: 7:35-8:05 PM
(2-Day Camp Mon & Wed)

First Name:

Last Name:

Date of Birth:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Job Title:

Work Phone:

Email Address:

Emergency Contact Name and Number:

With 10 being excellent, I rate my fitness level at:

My Main Fitness Goal is:

My Fitness Goal at Camp is:

How did you hear about boot camp?:

If by referral, please provide name:

Payment Options. Please select one:
(Payment page will follow this form)

I will pay online using PayPal: Please commit! We need to know you are serious about getting started on your way to fitness success. Once committed, we can schedule your pre-evaluation. No Refunds!

Sorry, we no longer accept checks.

Attendance Pricing Options:

5-days per week x 4-Weeks ($299)

3-days per week x 4-weeks ($199)

Fitness Blast 2-days per week x 4 weeks ($49)

MEDICAL HISTORY QUESTIONNAIRE
All "YES" answers require a written explanation below

Question		Answer
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?:
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.

Please explain any "YES" answers above:

What size t-shirt do you wear?:
(For your FREE ADVENTURE camp t-shirt. Shirt not included with 30 minute Fitness Blast.)

What are your fitness goals for the next 3-months?: