Boot Camp Registration

Camp and Payment Information

You must make Selections on both location & session date below

Choose your camp frequency and cost.
5 days/week Boot Camp = $299 3 days/week Boot Camp = $219

Form of payment:
Check Visa Mastercard American Express Cash

$299 (5 days/week) | *$219 (3days/week)   *This option is for those who have other commitments in the early a.m. Since it is only a 4-week class, we do prefer you to attend the full 5-day a week program for best results and overall work-out! You can do it!

Personal Information

First Name (required field):

Last Name (required field):

Street Address

City

State

ZIP

Profession

Country

Date of Birth (required field):
(mm/dd/yyyy)

Phone Number

Work Number

Fax Number

Email Address (required field):

Self Assessment & Additional Information

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

I was referred by (required field):

How did you hear about us?:

Please specify publication / website / friend or other referral:

This is my first camp:

If you answered "no", when was the last camp you attended:

My Main goal is:

Name of Emergency Contact & Phone Number (required field):
/

Medical History

(If you are a returning camper, only complete the sections that have changed.)

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

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

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:

Heart Disease:
Yes No

Lung Disease:
Yes No

Kidney Disease:
Yes No

Liver Disease:
Yes No

. 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

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?
Yes No If yes, what percent is it?

20. Are you training for a specific event? If yes, explain:

Release

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

RELEASE
This release is entered into between the undersigned and Cincinnati Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Cincinnati, Ohio. The purpose of Cincinnati Adventure Boot Camp 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 Brian Calkins is not a physician and is 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 that Cincinnati Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Brian Calkins including Cincinnati Adventure Boot Camp 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 Cincinnati Adventure Boot Camp 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 Cincinnati Adventure Boot Camp including Brian Calkins 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.

Customer client agrees to confidentiality with respect to Cincinnati Adventure Boot Camp and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of Cincinnati Adventure Boot Camp.  The undersigned agrees to a non-compete within a 50 mile radius of Cincinnati for a period of  5 years from date of participation.

Checkmark the following:

I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence.

I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence.

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 injured or become pregnant and unable to complete the one I originally joined. Camp fees can not be used towards any other products or services provided by Cincinnati Adventure Boot Camp.

I will remember to set my alarm and be at camp on time.

I understand that diet and nutrition will effect my fitness goals and performance during boot camp.

I will bring a positive attitude, and expect to have fun

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)