2010 Body Transformation Registration Form

Name	* required
Address
Home Phone
Cell Phone	* required
Email Address
Date of Birth
2009 Package you are registering for:	2010 Transformation Package ($1700)
Emergency contact name and number:
What is your main goal?
What location are you registering to attend?	Centennial Park: 5:15am (women only)
How did you find us?  Please be specific.  Thanks!	Internet Search Health & Fitness Magazine Pearland Community Newsletter Space City Parent Friend Referral (tell us who below, so we can thank you) Other...please explain.
Are you planning to attend the FREE nutrition lecture the first Monday evening of boot camp?	Yes No
Medical History Please note:  Is is wise to seek your doctor's advice before beginning a fitness program.
1.  Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?	Yes No If yes, please list:
2.  Do you take any prescribed medication on a permanent or semi-permanent basis?	Yes No If yes, please list:
3.  Do you have a seizure disorder (epilepsy)?	Yes No
4.  Do you have diabetes;  Type I (IDDM) or Type II (NIDM)?	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
7.  Do you have or have you ever had Heart Disease?	Yes No
8.  Do you have or have you ever had Lung Disease?	Yes No
9.  Do you have or have you ever had Kidney Disease?	Yes No
10.  Do you have or have you ever had Liver Disease?	Yes No
11.  Do you have or have you ever had asthma?	Yes No
12.  Do you have or have you ever had severe neck injury?	Yes No
13.  Have you ever been knocked out?	Yes No
14.  Have you had a broken bone or fracture in the past 2 years?	Yes No
15.  Do you wear glasses or contact lenses?	Yes No
16.  Have you ever injured your back?	Yes No
17.  Do you have back pain?	Yes No
18.  If yes, select the best answer:	Never Almost Never Seldom Occasionally Frequently
19.  Do you have other physical conditions, which cause pain?  Please explain.
20.  Have you had any surgical procedures?  Please, explain.
21.  Have you had knee pain in the past 2 years that has disabled you for longer than a week?	Yes No
22.  Have you ever had your body fat tested?	Yes No
23.  Are you training for a specific event?	Yes No
24.  What are your goals for the next 3 months?
25.  First time participants will receive a free t-shirt.  What is your T-shirt size?	S regular style M regular style L regular style XL regular style XXL regular style S baby doll style M baby doll style L baby doll style XL baby doll style
RELEASE This release is entered into between the undersigned and Adventure Boot Camp-Pearland, its officers, subsidiaries, affiliates, and executors.  The purpose of the Adventure Boot Camp program 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:  1. Acknowledges that Vince Garcia and the trainers working for Adventure Boot Camp are not  physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.  2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but Adventure Boot Camp and its trainers do not guarantee neither good nor bad will occur nor guarantees the training advice given by these trainers, 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/activities including the elements of a natural environment, 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 Adventure Boot Camp, Vince Garcia, the employees of Adventure Boot Camp and the City of Pearland 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 representative of Adventure Boot Camp or Vince Garcia 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. Yes, by checking this box I agree to the terms above. (A signed copy will also be required.)
PERFORMANCE PLEDGE In the spirit of harnessing your best effort and providing optimum results from your Boot Camp experience, we have established the following policies to which you will need to adhere.   I agree not to use foul language during Boot Camp. I agree not to 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 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 Adventure Boot Camp-Pearland.   Yes, by checking this box I agree to the terms above.
I understand that once I submit payment there are no refunds.  Only in the case of a medical condition, and written notice from a doctor, would I be able to freeze my 2010 Platinum Package and use in 2011.  I understand I am paying for all boot camps in 2010 and there are no roll overs or refunds.	* required
PAYMENT: Space is limited.  To reserve your spot send in payment immediately.	Paying online with credit card (After submitting this form, return to Payment tab to pay.) Mailing in a check (Make check payable to Phlex Fitness)