Boot Camp Registration

St. Louis Adventure Boot Camp Class
REGISTRATION

You have 2 options:
A. You can print this form and send it in with payment by mail.
B. Pay via secure Paypal over the internet, then fill out and submit the online form below.
You don't need a Paypal Account to use this service. (Select "Shipping Information is not required").
After "Checking Out" with Paypal, please fill out and submit the online form below.

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

If paying by mail, submit the registration then contact us for mailing details:
St. Louis Adventure Boot Camp
Contact Sarge or Joy directly for Check payment information.
losingbooty@yahoo.com
Phone: (314) 259-1177 office or (314) 435-9229 cell

You may pay by Credit Card or Check through secure paypal check out. Just click on the applicable paypal link and fill out the registration form and hit submit.

$299 (5 days/week)	$249 (4 days/week)	$199 (3 days/week)	$149 Holiday Express Camp (DECEMBER ONLY)

Also Available: Nutritional & Dietary Consultation. For more information call (314) 435-9229 or e-mail us at losingbooty@yahoo.com

Choose your payment option then please fill out the form below and click Submit . . . I am ready to get fit!"

You will be notified to schedule your pre-camp evaluation (if needed for your program).
Name
Address
City
State
ZIP
Profession
Country
Date of Birth	(mm/dd/yyyy)
Phone Number		Work Number
Fax Number
Email Address
I rate my current fitness level as a (1-10), ten being high.
I was referred by:
How did you hear about us?:		Please specify publication / website / friend or other referral:
This is my first camp:	Yes \| No	If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number
Indicate your T-shirt size.
What is the Event Name (from the Calendar) & which amount of days are you joining?

Form of payment:
If paying by check, please make payable to: St. Louis Adventure Boot Camp Creve Coeur, MO losingbooty@yahoo.com Phone: (314) 259-1177 office or (314) 435-9229 cell 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.)?
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes Adult or Juvenile?		List Medications:
5. Have you ever been found to be anemic (low blood count)?
6. Do you have High Blood Pressure (hypertension)?		List Medications:
7. Do you have or have you ever had the following diseases?
	Heart Disease:
	Lung Disease:
	Kidney Disease:
	Liver Disease:
8. Do you have asthma?		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?
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?		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! RELEASE This release is entered into between the undersigned and St. Louis Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of St. Louis. The purpose of St. Louis 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 Joyce M. Brown 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 St. Louis Boot Camp including St. Louis Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by St. Louis Boot Camp including St. Louis 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, 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 St. Louis 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 St. Louis Boot Camp including St. Louis Adventure Boot Camp 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. 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 not able to complete the one I originally joined. Camp fees can not be used towards any other products or services provided by St. Louis 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! Your signature will be required at the time of your evaluation and by submitting this registration form you agree to the terms now! ____________________ Signature ____________________ Printed Name ____________________ Date
I agree to all Terms and Conditions listed above

For More Information, Contact us at (314) 259-1177 office (314) 435-9229 cell or e-mail losingbooty@yahoo.com

St. Louis Adventure Boot Camp Class REGISTRATION

St. Louis Adventure Boot Camp Class
REGISTRATION