You now have two options:
A. You can print this form and send it by mail, or
B. Click the "Buy Now" link to register immediately "SECURE"
online. If you do not have a PayPal account, simply click on
the "Click Here" link at the bottom of the payment page, and
you will be able to enter your credit card information. You do NOT need
a PayPal account.
With either option, please email us and
let us know that you have registered and tell us which class time you
are planning to attend. We are nearly to the point where we are
going to be required to limit campers, so this is extremely important!
4-week camp
$299 (5 days/week)
|
$249 (4 days/week)
|
$199 (3 days/week)
|
| |
|
|
If you chose to pay by check, follow these instructions:
1. Print your information clearly or type
the information required.
2. Mail to:
Jeremy Nelms - Prescott Adventure Boot Camp
1 Kingswood Drive
Prescott, AZ 86305
If you are paying by check, please make payable to: Xtreme
Conditioning
3. Do not count on the mail being fast! You need to either email
or call to schedule your pre-camp evaluation.
Name:______________________________________
Street: ______________________________________
City : _______________________________________
State :______________________________________
Zip:_______________
Profession: _________________________________
Date of Birth ___/___/___
Home Phone (_____)____________________ Work
Phone (_____)_____________________
E-mail ______________________________
I rate my current fitness level as a _____ (1-10), ten being high.
I was referred by ______________________________________________________________________.
My main goal is to ____________________________________________________________________.
Emergency Contact and phone number______________________________________________________
What is the year, name & time of the program you are joining?
__________________________________________________
Price of program $ _____
Please choose your camp.
Camp Time: ______ 5:30 am _______
9:00 am _______
6:00 pm
2008
___ Camp 1 ___ Camp 2 ___ Camp 3 ___
Camp 4 ___ Camp 5 ___ Camp 6 ___
Camp 7 ___Camp 8
___ Camp 9
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MEDICAL HISTORY
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
List Medications:
5. Have you ever been found to be anemic (low blood count)? Yes / No
6. Do you have High Blood Pressure (hypertension)? Yes / No
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. Do you have asthma? Yes / No
List Medications:
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?
Never | Seldom | Occasionally |
Frequently with vigorous exercise or heavy lifting
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!
This WAIVER AND RELEASE is entered into between the Undersigned (below)
and: Prescott Boot Camp, Xtreme Conditioning, Prescott Racquet Club,
and The Dance Studio, including their agents, staff, employees, owners,
officers, trustees and instructors. This agreement applies to (1) personal
injury (including death) from accidents or illnesses arising directly
or indirectly from participation in activities directed, suggested,
or planned by Prescott Boot Camp, Xtreme Conditioning, Prescott Racquet
Club, and The Dance Studio but not limited to, organized activities,
classes, instruction, observation, related activities in a non-supervised
setting; and (2) any and all claims resulting from the damage to, loss
of or theft of property.
I declare that I wish to participate in an exercise program, and I
understand that I may do so only upon the following conditions and agreements.
1. I understand that any staff, employees or trainers of Prescott Boot
Camp, Xtreme Conditioning, Prescott Racquet Club, and The Dance Studio
are not medically licensed and are not trained in any way to provide
medical advise, diagnosis or intervention. I acknowledge that if I am
experiencing any sensation out of the ordinary relating to exercise
and training with Prescott Boot Camp, Xtreme Conditioning, Prescott
Racquet Club, and The Dance Studio, I will contact my physician immediately.
2. I hereby represent and warrant to Prescott Boot Camp, Xtreme Conditioning,
Prescott Racquet Club, and The Dance Studio that I am physically capable
of participating in the program without injury and that I am not aware
of any physical illness or condition that could increase my risk of
injury during such participation.
3. I understand that Prescott Boot Camp, Xtreme Conditioning, Prescott
Racquet Club, and The Dance Studio are resources to educate and train
me on physical exercise and nutrition, but in no way are results guaranteed.
I further recognize that the advice given to me by any staff, employee
or trainer of Prescott Boot Camp, Xtreme Conditioning, Prescott Racquet
Club, and The Dance Studio is not guaranteed to produce any type of
results, whether positive or negative.
4. I recognize that there are risks of injury associated with participation
in personal training for individuals who are overweight, elect to participate
without appropriate shoes, or are of an age or physical condition that
make illness, injury or death as a result of participation more likely.
I am aware of the risks inherent in any group fitness exercise program,
including but not limited to severe personal injury and death. I understand
that through my participation in personal training, I am subject to
possible injury and death, and also understand that by my participation,
I accept the risk of possible injury and death.
5. In order to participate in personal training, I hereby WAIVE and
RELEASE Prescott Boot Camp, Xtreme Conditioning, Prescott Racquet Club,
and The Dance Studio, their agents, staff, employees, owners, officers,
trustees and instructors from any and all claims, costs, liabilities,
expenses or judgments, including but not limited to attorney’s
fees and court costs (collectively “claims”) arising out
of my participation in personal or group training. I also agree to indemnify
and hold harmless Prescott Boot Camp, Xtreme Conditioning, Prescott
Racquet Club, and The Dance Studio from and against any and all such
Claims.
6. I hereby voluntarily execute and deliver this WAIVER AND RELEASE
so that I may participate in any and all Prescott Boot Camp, Xtreme
Conditioning, Prescott Racquet Club, and The Dance Studio fitness programs.
I have read and understand the above WAIVER AND RELEASE.
Please initial:
________ I understand and voluntarily agree to all the conditions and
agreements listed on this WAIVER and RELEASE.
________ I understand that there are risks of injury involved in participating
in exercise, and I voluntarily assume such risks.
________ I attest that I am physically fit to participate in the personal
or group fitness program.
________ I attest that I am 18 years old or older. (If not, legal guardian
must sign.)
Printed Name of Participant _________________________________
Signature of Participant _____________________________________ Date
___________
Signature of Parent/Guardian ________________________________ Date ___________
(If participant is under 18 years of age)
The Undersigned agrees that this is the full agreement between the
parties, that Prescott Boot Camp, Xtreme Conditioning, Prescott Racquet
Club, and The Dance Studio, 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.
____________________
Signature
____________________
Printed Name
____________________
Date
jeremy@prescottbootcamp.com
$299 (5 days/week)
$249 (4 days/week)
$199 (3 days/week)
