Boot Camp Registration Form for Women

Personal Details

Full Name
Address
City
Province
Postal Code
Profession
Date of Birth
Emergency Contact & Phone:
Home Phone
Work Phone
Cell Phone
Fax Number
Email Address
Favourite Workout Song

Choose your Camp!

Please select a Boot Camp to attend
GST REG# 86592 6083 RT0001

Would you like to attend the 3 day or 5 day camp?

Save money with the Early Bird!

*GST has been included in these prices

If you selected one of the regular Boot Camps from the drop down list above, please make a choice from the selections below.

3 Day Boot Camp $239 + GST ($250.95)
5 Day Boot Camp $349 + GST ($366.45)

If you selected one of the 'mini-camps' from the drop down list above, please make a choice from the selections below.

3 Day Mini Camp $119.50 + GST ($125.48)
5 Day Mini Camp $174.50 + GST ($183.22)

Is this your first boot camp?

Yes
No

If NO, when did you attend the last camp?

I would rate my current fitness level as a:

(1-10) - ten being high

My main goal is to:

How did you hear about our Boot Camp?

from a friend	Please provide your friend's name
internet search	Please provide the search terms you used
other	Tell us how else you heard about us

cost

Medical History

1. Are you allergic to any medication? (aspirin, penicillin, sulfa, etc.)

yes
no

If "yes", please list allergies:

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

yes
no

If "yes", describe:

3. Do you have a seizure disorder? (example: epilepsy)

yes
no

If "yes", list Medications:

4. Do you have Adult or Juvenile diabetes?

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

If "yes", list Medications:

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

Heart Disease	yes	no
Lung Disease	yes	no
Kidney Disease	yes	no
Liver Disease	yes	no

8. Are you currently pregnant?

yes
no

If "yes", how long and are there any complications?

9. Do you have asthma?

yes
no

If "yes", list Medications:

10. Have you ever had a severe neck injury?

yes
no

If "yes", describe:

11. Have you ever been knocked out?

yes
no

If "yes", describe:

12. Do you wear glasses or contact lenses?

yes
no

13. Have you had a broken bone or fracture in the past 2 years?

yes
no

If "yes", describe:

14. Have you ever injured your back?

yes
no

If "yes", describe:

15. Do you have back pain?

Never
Seldom
Occasionally
Frequently with vigorous exercise or heavy lifting

16. Have you had knee pain in the past 2 years that has disabled you for longer than a week?

yes
no

If "yes", describe:

17. Do you have other physical conditions which cause pain?

yes
no

Describe:

18. Have you had any accidents or major surgery that may limit your exercise capability?

yes
no

If "yes", describe the accidents or major surgery:

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

Describe your goals:

20. Have you had your body fat tested?

yes
no

If "yes", what percent is it?

21. Are you training for a specific event?

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

yes
no

If "yes", describe

BOOT CAMP PROTOCOL: Please Check Off The Following!

	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 not to eat or say the words Twinkie, Donuts, Chocolate Bar, Hot-Dog, Potato Chips, 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 agree that I will not speak when the Boot Camp instructor is providing direction, as this slows down the camp pace, is unsafe and is disrespectful to other Boot Campers. Any violation will result in 20 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 a no refund policy and that I cannot transfer partially unused sessions to a following boot camp program, and that My Boot Camp fees cannot be used towards any other products or services provided by My Adventure Boot Camp, Inc.
	I understand and accept that the unauthorized solicitation of products or services to Boot Campers is strictly prohibited and will result in an immediate and permanent dismissal from Boot Camp.
	I understand and accept that My Adventure Boot Camp reserves the right to refuse service to any individual that may be unsuitable for the Boot Camp Program.
	I understand, agree to and accept that I may not use or teach any of the exercises and/or activities learned during Boot Camp for revenue purposes, and that legal action may be taken against me, unless I have undergone special instructor training and received written authorization from My Adventure Boot Camp.
	I will remember to set my alarm and be at camp on time.

Release Notes

This release is entered into between the undersigned and My Adventure Boot Camp Inc., its officers, affiliates, and executors in addition to the City of Vancouver Parks Board, Eric Hamber Secondary School, Emily Carr Elementary School and Pro FIT Professional Fitness Coaching Systems. The purpose of My 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:

Acknowledges that T’ai Erasmus is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that My Adventure Boot Camp, Inc. does not guarantee neither good nor bad will occur nor guarantees the training advice given by My Adventure Boot Camp, Inc. will produce good nor bad results.
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.
Acknowledges that boot camps, TRX camps, aerobic classes, boxing, agility training, running, weight training, obstacle courses, stretching and any other related sports/activities 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 My Adventure Boot Camp, Inc. 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 My Adventure Boot Camp, Inc. 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.

I acknowledge that I have read, understand and agree to all of the above stated release notes.

BY PRESSING THE SUBMIT BUTTON BELOW, YOU ARE AGREEING TO THE BOOTCAMP PROTOCOLS LISTED ABOVE.
A SIGNATURE TO THIS EFFECT WILL BE REQUIRED AT YOUR INITIAL EVALUATION.