Success Boot Camp REGISTRATION:

Get Ready for a Whole New Life!

Please fill out the Registration Form below to enroll with Success Boot Camp.

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

Name
Address
Street AddressCityStateZip Code
Profession
Country
Date of Birth
Phone Number
Cell 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
When was the last camp you attended?
My main goal is
Name of Emergency Contact
Phone Number of Emergency Contact
Which State is your camp located in?
Which city is your camp located in?
Form of payment
Medical History
(If you are a returning camper, only complete the sections that have changed)
Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
List Medications
Do you take any prescribed medication on a permanent or semi-permanent basis?
List Medications
Do you have a seizure disorder (epilepsy)?
List Medications
Do you have diabetes Adult or Juvenile?
Have you ever been found to be anemic (low blood count)?
Do you have High Blood Pressure (hypertension)?
List Medications
Do you have or have you ever had the following diseases?
Heart Disease
Lung Disease
Kidney Disease
Liver Disease
Do you have asthma?
List Medications
Have you ever had a severe neck injury? Please describe
Have you ever been knocked out? Please describe
Do you wear glasses or contact lenses?
Have you had a broken bone or fracture in the past 2 years? Please describe
Have you ever injured your back? Please describe
Do you have back pain?
Have you had knee pain in the past 2 years that has disabled you for longer than a week? Please describe
Do you have other physical conditions which cause pain? Please describe
Detail any surgical procedures
What are your goals for the next three months?
Have you had your body fat tested?
What percent is it?
Are you training for a specific event? Please describe
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 North Texas Boot Camp LLC DBA Success Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the location of subject camp. The purpose of Success Boot Camp including Success Boot Camp trainers 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. 1. Acknowledges that Success Boot Camp trainers are not a physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
2. 2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Success Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Success Boot Camp trainers including Success Boot Camp will produce good nor bad results.
3. 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. 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 Success 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 Success Boot Camp including Sucess Boot Camp trainers 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 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 Success 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 you agree to the terms now!

Please complete the name and date fields below to electronically sign this form.
- I agree to all Terms and Conditions listed above
Name
Date

Boot Camp Registration

Success Boot Camp REGISTRATION:

Medical History

Release