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Text Box: Boot Camp Challenge Registration Form Fit 360, LLC. Boot Camp Challenge REGISTRATION FORM *Form and Payment In Full must be returned to civic center or mailed to Fit 360, LLC. 4806 Chestnut Oval, Independence, Oh 44131 *Prior To First Session NAME:_________________________________________________________________ ADDRESS:______________________________________________________________ CITY:___________________________ STATE:______________ ZIP:____________ HOME PHONE:_______________________ WORK PHONE:____________________ CELL PHONE:_________________________________*Note: For very important use if boot camp is cancelled due to weather conditions! EMAIL:_______________________________@________________________________ DATE OF BIRTH: ________/_______/_______ *AGE__________________________ EMERGENCY CONTACT NAME & NUMBER:_______________________________ PROFESSION:___________________EMPLOYER_____________________________ *Would your company be interested in Corporate Boot Camps, Small Group Personal Training Sessions or Corporate Wellness Programs? Circle All That Apply. I rate my current fitness level as a ___________ (1-10), ten being high. My main goal is to:________________________________________________________ I will be paying by: (circle one) Check Cash Date Paid:____/____/___ *Note: If paying by check, please make checks payable to Fit 360, LLC. Independence Civic Center Members Fee $180 and NonMembers $240 4806 Chestnut Oval Independence, Ohio 44131 PLEASE ARRIVE 15 MINUTES EARLY FOR FIRST SESSION! *Note: There will be a discount for “re-enlisting” in future consecutive camps. Name__________________________________Date_________ Age__________ Registration Form Page 2 Medical History Form Check those that apply ___Heart attack, coronary bypass, cardiac surgery, stroke ___Family history of heart disease or sudden death in Father or male siblings prior to age 55, or before 65 in Mother of female siblings. ___Do you have chest pain at rest or exertion? Do you have uneven, irregular or skipped heart beats (including a racing or fluttering heart)? ___High Blood Pressure (hypertension) greater than or equal to 140/90 mmHg. (or on blood pressure medication) ___Do you have (asthma, emphysema or bronchitis) circle all that apply ___Do you have a seizure disorder (epilepsy) ___Diabetes ___Kidney or Liver Disease (circle all that apply) ___Are you a smoker? ___Are you anemic (low blood count)? Light Headed or fainting? ___Orthopedic problems (to include arthritis or any other bone/ joint/muscle disorder) ___Have you ever had a sever neck injury? Describe: ___Have you had a broken bone or fracture in the past 2 years? Describe: ___Do you have back pain? Never/Seldom/Occasionally/Frequently with vigorous exercise or heavy lifting ___Have you ever injured your back? ___Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe: ___Do you have other physical conditions which cause pain? Describe: ___Are you currently pregnant? ___Recent illness, hospitalization or surgical procedure What are your goals for the next three months? Have you had your body fat tested? If yes, what percent is it? Are you training for a specific event? If yes, explain. *Note: If you are a male over age 45 and Female over age 55, have cardiopulmonary or metabolic disease, have high blood pressure or high cholesterol, are a cigarette smoker, or have 2 or more above risk factors, the American College of Sports Medicine (ACSM) requires a Physician’s Clearance prior to any vigorous exercise program. It is always REGISTRATION FORM PAGE 3 wise to seek your physicians advice before participating in any halth/fitness or nutrition progam. *I understand it is my responsibility to provide the Physicians Release to Fit 360, LLC Boot Camp Challenge prior to starting this program if I have 2 or more risk factors. I will notify the instructor if anything should change in my health status. I realize that it is my responsibility to inform the instructor should any changes occur. Sign_____________________________Date__________________ Physician’s Exercise Release I have examined_______________________________________________________________ I have found the following: The above named may participate fully in a progressive physical activity program consisting of cardiovascular, strength, and flexibility training without limitation. or — ■ The above named may participate in a progressive physical activity program with the following limitations: Please List Limitations:
________________________________________ Physician’s Name x________________________________________ _________________ Physician’s Signature Date REGISTRATION FORM PAGE 4 Informed Consent Waiver / Release and Hold Harmless Agreement for Fitness Program Participant Aerobic, Muscular, Flexibility, Body Composition Fitness Programs I, the undersigned participant, am hereby enrolling in a program of strenuous physical activity including, but not limited to, aerobic, martial arts, running, obstacles courses, boot camps, dance, weight lifting, stationary bicycling, and the use of various aerobic conditioning machinery, tubing and any/all sports related exercise offered by (Fit 360, LLC.). I have been strongly encouraged to consult with my physician prior to starting an exercise program or increasing the intensity of an existing program, indicated both in this document and by (Fit 360, LLC.). I assume this responsibility as indicated by my below signature and if I choose to, will act on this advice prior to the implementation of any recommendations made by (Fit 360,LLC). I hereby affirm that, to the best of my knowledge, I do not suffer from any condition that would prevent or limit my participation in this fitness program and have not withheld any related information from (Fit 360, LLC). In the event that through screening, I have been determined to be other than apparently healthy, I have been given a physician’s release, as required by (Fit 360, LLC) to exercise. I am taking no medications that may adversely affect my fitness activities, and this release, with or without physician’s restrictions, has been given to (Fit 360, LLC). In addition, I acknowledge that if my health changes, it is my responsibility to recognize the change and seek medical advice to help me decide if my continued participation in the fitness program or any part of the fitness program is still right for me. I fully understand that I may injure myself as a result of my participation in (Fit 360, LLC) fitness program and I hereby release (Fit 360,LLC.), its Board, employees and agents, Independence Civic Center from any liability now or in the future for any injury. Injuries may include, but are not limited to, heart attacks, death, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries, and any other illness, soreness, or injury, however caused, occurring during, or after, my participation in the fitness program offered, unless caused by the trainer’s recklessness or intentional misconduct. In consideration of my participation in (Fit 360, LLC.) fitness program, I, for myself, my personal representatives, administrators, heirs and assigns, hereby holds harmless (Fit 360, LLC.), its Board, employees and agents, from any claims, demands, and causes of action, to include reasonable legal expenses and attorney’s fees arising from my participation in the fitness program, unless caused by the trainer’s recklessness or intentional misconduct. I hereby affirm that I have read, have been honest with (Fit 360, LLC.), and fully understand the above information. I have been given the opportunity to present questions in all related matters. x________________________________________________ SIGNATURE OF FITNESS PROGRAM PARTICIPANT x_____________________________________________ x__________________________ P RI NTED NAME DATE REGISTRATION FORM PAGE 5 Policies and Procedures 1. Heart monitor recommended during exercise program. When exercising by feel, you may not be elevating your heart rate enough to generate cardiovascular and weight loss benefits. *You can purchase one from Dicks or your favorite sporting good store. *This ensures your heart rate does not exceed your Max heart rate. Complete Registration Form Prior To Exercise Program Start Date. Provide Complete Physician Release Form if 2 or more risk factors. Payment in full prior to first session. Sessions last one hour. I understand by consuming alcohol during the month of boot camp will not help me achieve my goals. I agree to not eat or say the words Donuts, Cookies, Cup Cake, Chocolate, or Twinkies during the course of Boot Camp. I understand that these items will not help me achieve my goal. I understand that photos or video from media may be taken during boot camp, which may be used for promotional purposes. Bring Tennis Shoes, Towel and Water to session! 10 .The undersigned participant hereby agrees not to directly or indirectly compete with the business of Fit 360, LLC Boot Camp Challenge or other Fitness Related programs and it’s successors and assigns during the period of participation and for a period of one year following end of participation. The term “non compete” as used herin shall mean that the undersigned shall not own, manage, operate, consult or to be employed in a business substantially similar to, or competitive with, the present business of Fit 360, LLC, specifically Boot Camp Challenge. I understand there is no refun policy, but I can receive a credit (for unused portion of amp) toard a futre camp if I’m unable to complete the one I originally joined. Camp fees cannot be used towards any other products or ervices provided by Fit 360, LLC. I understand that it is important to be prompt when participating the exercise program so I can participate in the warm-up exercises at the beginning of camp to prevent injury. Client Signature:_______________________________Date:_________________ Fit 360 Signature: Fit 360, LLC Date:____January 12, 2008_____________