Registration form

REGISTRATION FORM

Total Body Fitness

Nevada County Boot Camp

P.O. Box 2906

Grass Valley, CA 95945

530-477-2946

Fax: 530-687-8099

REGISTRATION

Are you ready to start your adventure? Follow these instructions:

1. Print your information clearly or type.

2. Reply by e-mail (karen@ncbootcamp.com) or phone 530-477-2946 ( attn: Karen)

3. You will be notified to schedule your pre-camp evaluation.

I accept cash and checks. Please make checks payable to Total Body Fitness

Your payment is due in full at the pre-evaluation.

YES, I'm ready for the Adventure Boot Camp. Sign me up!

Name:______________________________________

Street:______________________________________

City:_______________________________________ Sate:______

Zip Code:_______________

Profession: ______________________________

Date of Birth ___/___/___

Emergency Contact and phone number_________________________________

I'm signing up for the camp beginning on this date______/_______/______.

This is my first camp __________

The last camp I attended was _______________

Home Phone (_____)____________________

Work Phone (_____)_____________________

Fax Number (___)_______________________

E-mail _________________@_____________

I rate my current fitness level as a _____ (1-10), ten being high.

I was referred by ______________________________.

My main goal is to _________________________________________________.

Payments can be made by cash, check, Master Card, Visa, Discover or AMEX

Name on the Card: ____________________________________

Credit Card Number: ___________________________________

Card Expiration Date: ___________

CVC Code* _________

Your Signature: _______________________________________

*Visa and Mastercard

In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a special 3 digit code. This 3 digit code is your CVC.

American Express

On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code.

Please check off package you are interested in:

Option #1 - 5 days per week for $299

Option #2 - 3 days per week for $199 *** Butts & Guts is ONLY offered as a 3-days per week

Confirmations and detailed instructions will be mailed prior to the start of Camp. Waiver must be signed prior to participation.

MEDICAL HISTORY

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1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? Yes No

Please List ___________________________________________________

2. Do you take any prescribed medication on a permanent or semi-permanent basis? Yes No

Please List ___________________________________________________

3. Do you have a seizure disorder (epilepsy)? Yes No

4. Do you have diabetes Adult or Juvenile? 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 the following diseases?

A) Heart Disease: Yes No B)Liver Disease: Yes No C) Lung Disease: Yes No D) Kidney Disease: Yes No

8.. Do you have asthma? Yes No

9. Have you ever had a severe neck injury? Yes No