NYC Boot Camps


	Dramatics improvements in your physical well-being and self confidence.

Expected results when you
complete camp are:

	3-5% reduction in body fat
	Drop 6-12 pounds in four weeks
	Get tighter, flatter, sexier abs
	Firmer arms, thighs and butt
	Look and feel ten years younger
	Increase energy and stamina
	Fun energizing indoor / outdoor workouts

Congratulations! Please complete the registration form below and you are on your way to a total fitness!

Contact Details

Name:
Surname:
Mailing Address:
City:
State:
ZIP code
Physical Address (if different from above):
Profession:
Date of Birth:
Phone Number:	Numbers Only- NO dash or space
Mobile Number:	Numbers Only- NO dash or space
Email:
Name of Emergency Contact & Phone Number:
Which location are you registering for?
Which weekdays option are you registering for?
Which time would you like to register for?

Medical Information

1. Are you allergic to any medication (aspirin, penicillin,sulfa, etc.)?		List Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?		List Medications:
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 (lowblood 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 hasdisabled you for longer than a week? Describe:
16. Do you have other physical conditions which cause pain? Describe:
17. Detail any surgical procedures:
18. Have you had your body fat tested?	If yes, what percent is it?
19. Are you training for a specific event? If yes, explain:
20. I rate my current fitness level as a:	(use a scale of 1-10, with 10 being the highest = an elite athlete)
21. My main goal when it comes to fitness is:
22. How did you hear about our boot camp? If by referral, please provide the name:

Informed Consent, Waiver, and Release Agreement

This release is entered into between the undersigned and NYC Boot Camps, its officers, subsidiaries, affiliates, and executors in addition to the NYC Township. The purpose of NYC Boot Camps 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 Alan Courtenay 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 NYC Boot Camps does not guarantee neither good nor bad will occur nor guarantees the training advice given by NYC Boot Camps 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 NYC Boot Camps for the undersigned participating in said sporting events and/or training for said sporting events.

5. Acknowledges that there is no refund policy after 30 days, but I can receive credit ( for unused portion of camp ) toward 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 NYC Boot Camps.

6. That I must meet with the trainer one week before start of the camp to fill out the rest of the registration and medical forms.

7. I agree to provide NYC Boot Camps 30 days in advance notice of cancellations or any changes that might affect my schedule in order to receive adjustments in my monthly current rate.

8. I understand that photo and videos 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.

The Undersigned agrees that this is the full agreement between the parties, that NYC Boot Camps 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 to all Terms and Conditions listed above