Registration

Submitted by Anonymous on Tue, 05/26/2009 - 13:32

Portland Boot Camp Registration and Release Form

NOTE: 5:30 camps are restricted to WAIT LIST members only. To join the wait list, email support@portlandbootcamp.com. To join the 7:30 or 9:00 classes, register below.

Contact Info

First Name: *

Last Name: *

Profession: *

Address: *

City: *

Zip: *

Email: *

Phone Number: *

Best Time to Call Me: *

Camp Selection

Please carefully select the camp you want to join from the pull-down menu to the right. NOTE: Spots are only available for 7:30AM and 9AM camps at this time. You cannot register for a 5:30am class unless invited from Wait List.

Camp Selection: *

Days Per Week - 4 Week Camp (Camps 1 - 6 and 8 - 9 2010 are all 4 week camps):

5 Days per Week: $299

4 Days per Week: $249

3 Days per Week: $199

Days Per Week - 3 Week Camp (NOTE: 3 Week Camp option is available for Camp 7 & Camp 10 2010):

5 Days per Week: $229

4 Days per Week: $199

3 Days per Week: $149

Personal Info

Tell me about yourself and your fitness goals. NOTE: If you have not exercised for more than a year, or your medical history below is deemed too restrictive or dangerous for Boot Camp, I may refer you to another service instead of Adventure Boot Camp at this time.

Height: *

Weight: *

Age: *

I estimate my fitness level is:
(1-10, 10 is high): *

NOTE: If your fitness level is 3 or lower, contact Daniel before registering.

What is your fitness goal? : *

Are you training for a specific
sport or event? :

How did you find out about Adventure Boot Camp? (please be as specific as you can) : *

Medical History

Any NO answers may be left blank. If YES, please explain.

Are you allergic to any medication? :

Do take any prescription medications regularly or semi-regluarly? :

Do you have diabetes, Type 1(IDDM) or Type 2(NIDM)? :

Are you, or have you ever been found to be anemic? :

Please list any medical conditions here:

Have you ever had a severe neck injury? If so, please explain:

Have you ever blacked out or fainted?:

Have you ever injured your back? :

Have you broken a bone or fractured one in the last 2 years? :

Do you have back pain? If yes, please choose the best answer:

Have you had knee pain in the past 2 years that has disabled you for 7 days or more? :

Do you have any other regular pain? :

Have you had any surgeries? :

RELEASE

Boot Camp Release:

This release is entered into between the undersigned and Portland Adventure Boot Camp/Iversen Enterprises LLC. The purpose of Portland Adventure Boot Camp is to provide fitness instruction for various levels of athletes and individuals. The undersigned hereby acknowledges that the following was explained and/or agrees to the following:

1. Acknowledges that Daniel Iversen, nor any employee of Portland Adventure Boot Camp is 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 or individuals about themselves, but that neither Daniel Iversen nor Portland Adventure Boot Camp guarantees good nor bad will occur nor guarantees the training advice given will produce good nor bad results.

3. Acknowledges that the undersigned has been told that if they feel tired, feel pain, or feel out of the ordinary in any way either related to training, or otherwise, that the undersigned should contact a licensed physician at once.

4. Acknowledges that boot camps, aerobic classes, martial arts, kick boxing, running, sprinting, jumping, kung-fu, weight training, obstacle courses, and any other related sports or activities 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 sole risks of participating in these types of events/activities including the inherent dangers of the natural elements, 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 waives, releases, discharges, and agrees not to sue from any liability of death, disability, personal injury, or action of any kind and Portland Adventure Boot Camp/Iversen Enterprises LLC for the undersigned participating in said sporting events/activities and/or training for said sporting events/activities.

The undersigned agrees that this is the full agreement between the parties, that Portland 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, threat of force, fraud, or coercion.

By checking this box, I, the undersigned agree to the terms set forth above: *

I agree

A Unique Women's
Fitness Boot Camp Program

PORTLAND, OREGON

Registration

Portland Boot Camp Registration and Release Form

A Unique Women'sFitness Boot Camp Program

PORTLAND, OREGON

Registration

Portland Boot Camp Registration and Release Form

A Unique Women's
Fitness Boot Camp Program