Wufoo

Registration Form

Charlotte Adventure Boot Camp Registration Form. Remember, we cannot guarantee your spot in camp until we receive your payment.

My Name * Title First Last Suffix
Date of Birth * / MM / DD YYYY
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Cell Phone * - (###) - ### ####
Email *
Emergency Contact Name
Emergency Contact Phone * - (###) - ### ####
I rate my current fitness level from 1-10 (10 being highest = elite athlete)
My main goal is:
How did you hear about us? *
If a friend referred you please list their name here:
What size would you like for your FREE Adventure Boot Camp T-shirt?
This is my first camp
Choose your camp
Choose your days per week
Multiple Camp Registration (discounted pricing for multicamp purchases!)
Form of Payment

NOTE: If paying by check, please print this online form and mail or fax it in with payment. Please note we can not reserve your spot until payment is received.
Medical History Questionaire (check all boxes that apply) Checked boxes require a written explanation below Are you allergic to any medication? Do you take any prescribed medication on a permanent basis? Do you have a seizure disorder (epilepsy)? Do you have diabetes, Type I (IDDM) or Type II (NIDM)? Have you ever been found to be anemic? Do you have high blood pressure (hypertension)? Do you have or have you ever had kidney disease? Do you have or have you ever had liver disease? Do you have or have you ever had asthma? Do you have or have you ever a had severe neck injury? Have you ever been knocked out? Have you had a broken bone or fracture in the past 2 years? Have you ever injured your back? Do you have back pain? Have you had knee pain in the past 2 years that has disabled you for longer than a week? Do you have other physical conditions, which cause pain?
Please explain all checked boxes above:
Informed Consent, Waiver, and Release Agreement

The waiver and release is entered into between the undersigned and Charlotte Adventure Boot Camp its instructors, officers, affliliates, and executors.

The purpose of the Charlotte Adventure Boot Camp program offered by Jenny Patza is to provide fitness instruction and coaching for various levels of individuals.

The undersigned hereby acknowledges that the following was explained to me and/or agree to the following:

1. Acknowledges that Jenny Patza 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 individuals themselves, but Charlotte Adventure Boot Camp does not guarntee niether good nor bad will occur, nor guarntees the training advice given by Charlotte Adventure Boot Camp or its instructors, will produce good or 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, yoga, obstacle courses, and any other sport related activity 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 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 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 Charlotte Adventure Boot Camp, its instructors, officers, affiliates, and executors for the undersigned participating 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 Charlotte Adventure Boot Camp 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.
I agree to the above release agreement * By checking this box you have agreed to have read and understand the above consent and release agreement
Performance Pledge (by checking each box you agree to the following terms) * 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 (or 20 push ups) I understand that photos or videos may be taken during the course of my involvement in boot camp which may be used for promotional purposes I understand there is a no refund policy I commit to give 100% effort to my self at each class and the remaining 23 hours per day I am making a commitment to my self to change my lifestyle for better health & self improvement
Do Not Fill This Out

Wufoo

Registration Form

Informed Consent, Waiver, and Release Agreement