Nevada County Boot Camp Registration form

REGISTRATION INSTRUCTIONS

1. Type in information below for all fields.

2. Print out forms.

3. Sign and Date the Medical Release.

4. Mail forms to: Printable Form for mail

IronWorks Athletic Club

Karen Matthews

153 South Auburn St.

Grass Valley, CA 95945

5. If paying by check, please mail it with the paperwork.

Please make checks payable to Karen Matthews

(10 Day waiting period on Personal Checks)

E-MAIL REGISTRATION FORM

Name:

Street:

City:

State:

Zip:

Profession:

Date of Birth // (mm/dd/yyyy)

Home phone number Work Phone

I am signing up for the

This is my first camp

The last camp I attended was (date)

Emergency Contact

Contact #

Fax Number

E-mail

I rate my current fitness level as a

(1-10), ten being high.

How did you hear about us?

My main goal is to

I will be paying by:

* = We prefer if you attend M,W,F of each week. Most ladies decide to add days after enrolling in the 3-day program.

Which camp are you attending?

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

__________________________________________________________________________________

MEDICAL HISTORY

Please answer "Y" for Yes or "N" for No in the corresponding boxes

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

If Yes Please List:

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

If Yes Please List:

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

4. Do you have diabetes Adult or Juvenile?

5. Have you ever been found to be anemic (low blood count)?

6. Do you have High Blood Pressure (hypertension)?

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

Heart Disease:

Lung Disease:

Liver Disease:

Kidney Disease

8. Do you have asthma?

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?

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?

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. Have you had any surgical procedures: with-in the last 12 months?

Describe:

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!

____________________________________________________________________________________

MEDICAL RELEASE

This release is entered into between the undersigned and Nevada County Boot Camp / IronWorks Athletci Club, its officers and affiliates. The purpose of Nevada County Boot Camp is to provide fitness and exercise instruction and coaching for various levels of athletes/individuals.

The undersigned hereby acknowledges that the following was explained to them and/or agrees to the following:

1. Acknowledges that the Nevada County Boot Camp / IronwWorks Athletic Club owners and instructors are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, psychotherapy, or any other type of medical advice.

2. Acknowledges that fitness training is another tool for teaching individuals about themselves, but that Nevada County Boot Camp and its owners do not guarantee neither good nor bad will occur nor guarantee the training advice given by the owners/instructors 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 their training, or otherwise, that the undersigned should contact a physician at once.

4. Acknowledges that boot camps, aerobic classes, running, weight training, obstacle courses and any other related sports are an extreme test of one’s metal and physical limits and carries 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 Total Body Fitness/Nevada County Boot Camp/Anytime Fitness for the undersigned participating in said sporting/fitness events and/or training for said sporting/fitness events.

5. The Undersigned agrees that this is the full agreement between the parties, that

Nevada County Boot Camp / IronWorks Athletic Club 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.

This release is entered into between the undersigned and Nevada County Boot Camp / IronWorks Athletic Club / Karen Matthews, its officers, affiliates, and executors in addition to the County.

The purpose of Nevada County Adventure Boot Camp/ Karen Matthews is to provide fitness instruction and coaching for various levels of athletes/individuals.

The Undersigned agrees that this is the full agreement between the parties, that Karen Matthews, 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 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 Ice Cream, Donuts, Birthday Cake, Candy, or Pizza during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence.

I agree not to use the words, I can't, I'm too tired, I'm not in shape, It's too hard.

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 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 I'm not able to complete the one I originally joined. Camp fees cannot be used towards any other products or services provided by Karen Matthews, Anytime Fitness orTotal Body Fitness

I will remember to set my alarm and be at camp ON TIME.

*Signature _______________________________________

*Printed Name ______________________________________

*Date _____________________________________________

*(Signature and date will be signed during pre-evaluation)