Parker Boot Camp Women's Fitness Boot Camp Registration Form

Follow these instructions:

1. Print your information clearly or type
2. Fax to (303) 805-4504 or mail to:
Andy Alexander
11421 Romley Ct
Parker, CO 80134

If you are paying by check, please make payable to Body Tamer.
3. You will be notified to schedule your pre-camp evaluation.

Name:______________________________________
Street:______________________________________
City:_______________________________________
State:______________________________________
Zip:_______________
Profession: _________________________________
Date of Birth ___/___/___

Home Phone (_____)____________________ Work Phone (_____)_____________________
Fax Number (___)_______________________
E-mail _________________@_____________
I rate my current fitness level as a _____ (1-10), ten being high.
I was referred by ______________________________________________________________________.
My main goal is to ____________________________________________________________________.

Emergency Contact and phone number______________________________________________________

Name on the Card:
Credit Card Number:
Card Expiration Date:
CVC Code*
Your Signature:

*Visa and Mastercard
In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a special 3 digit code. This 3 digit code is your CVC.
American Express
On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code.

__________________________________________________
Price of program $149/4 days per week(4 week boot camp).

If paying by check, please make payable to Body Tamer.
11421 Romley Ct, Parker, CO 80134. Waiver must be signed prior to participation.

MEDICAL HISTORY (If you are a returning camper, only complete the sections that have changed.)

3. Do you have a seizure disorder (epilepsy)? Yes No
4. Do you have diabetes Adult or Juvenile? Yes No

List Medications:

5. Have you ever been found to be anemic (low blood count)? Yes No
6. Do you have High Blood Pressure (hypertension)? Yes No
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease: Yes No
Lung Disease: Yes No
Kidney Disease: Yes No
Liver Disease: Yes No
8. Do you have asthma? Yes No
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?
Never Seldom Occasionally Frequently with vigorous exercise or heavy lifting
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!

This release is entered into between the undersigned and Andy Alexander and Body Tamer, its officers, trainers, affiliates, executors in addition to the City of Parker. The purpose of Body Tamer 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 Andrew Alexander 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 Andrew Alexander and Body Tamer does not guarantee neither good nor bad will occur nor guarantees the training advice given by Andrew Alexander and Body Tamer 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 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 waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind and Andrew Alexander and Body Tamer for the undersigned participating in said sporting events and/or training for said sporting events.

5. Acknowledges that the Adventure Boot Camp has NO cash refund. Participants are expected to be prepared, consult with their doctor, and take responsibility for being fit enough to attend boot camp, regardless of whatever advice Andrew Alexander or anyone at Bodytamer may give. There are NO refunds, for any reason whatsoever after the camp has started. Only credit for a future camp will be considered. If cancellation is before camp starts, there will be a $50 administration fee that will not be refunded.

6. Acknowledges that there may be photographs and/or video taken during participation in boot camp. These may be freely used by Bodytamer and Adventure Boot Camp for advertising purposes without any compensation whatsoever.

7. Acknowledges and agrees to not start your own boot camp or similar program within 20 miles of Parker, Colorado, and within two years of completing your last boot camp with Bodytamer and Adventure Boot Camp.