Full Name:

  Address:

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Phone Number:       Cell Phone Number:      Fax Number:

Email: 

Occupation:        Date of Birth: (mm/dd/yyyy)

How did you hear about us? (Please be specific) 

This is my first camp:  Yes  No     If no, when was the last camp you attended?

I would like to register for the following camp: Choose one...

T-shirt size:   Choose one... Small Medium Large Extra Large

EMERGENCY CONTACT

Name:   Phone Number:   Relationship:

MEDICAL HISTORY

NOTICE:  It is always wise to seek your doctor's advice before beginning any health/fitness/nutrition program. If you have any injury or condition which might interfere with your ability to take part in strenuous exercise, or if you want to lose weight and are under 18, pregnant, nursing, following a diet recommended by a doctor, have health problems, or want to lose more than 30 pounds you should consult your physician before beginning Hall County Adventure Boot Camp. We reserve the right to require a signed physician's release before allowing any individual to take part in the program.

1. Are you allergic to any medications (aspirin, penicillin, sulfa, etc.)? Yes  No
If yes, please list.

2. Do you take any prescribed medication on a permanent or semi-permanent basis? Yes  No
If yes, please list.

3. Do you have a seizure disorder (epilepsy)? Yes  No

4. Do you have diabetes (adult or juvenile)? Yes  No
Please 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
Please list medications 

7. Do you have or have you ever had the following diseases?

8. Do you have asthma?  Yes  No
Please list medications

9. Have you ever had a severe neck injury?  Yes  No   If yes, please describe:

10. Have you ever been knocked unconscious (knocked out)?  Yes  No  If yes, please describe:

11. Do you wear glasses or contact lenses?  Yes  No

12. Have you had a fracture (broken bone) in the past 2 years?  Yes  No   If yes, please describe:

13. Have you ever injured your back?  Yes  No   If yes, please describe:

14. Do you have back pain with vigorous exercise or heavy lifting?  Choose one... Never Seldom Occasionally Frequently

15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?  Yes  No
If yes, please describe:

16. Do you have other physical conditions which cause pain?  Yes  No  If yes, please describe:

17. Have you undergone any surgical procedures?  Yes  No  If yes, please describe:

18. Have you ever had your body fat percentage tested?  Yes  No   If yes, what percent was it? 
 

19. I rate my current fitness level as a Choose one... 1 2 3 4 5 6 7 8 9 10 on a 1-10 scale (1=total couch potato; 10=elite athlete)

20. My primary fitness goal for the next three months is:

21 Are you training for a specific event?  Yes  No  If yes, please describe:

Waiver, Release and Agreements

This release is entered into between the undersigned and Johnny Reed (DBA Johnny Reed Enterprises and Hall County Adventure Boot Camp) and Hall County Parks & Leisure Services. The purpose of the Adventure Boot Camp program offered by Johnny Reed is to provide fitness instruction and coaching for various levels of athletes/individuals.

The undersigned hereby acknowledges that the following was explained to me and/or agrees to the following:

1. Acknowledges that Johnny Reed, or any other instructor for Hall County Adventure Boot Camp, 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 Johnny Reed and Hall County Adventure Boot Camp does not guarantee either good or bad will occur nor guarantee the training advice given by Johnny Reed and Hall County Adventure Boot Camp will produce good or 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 physician at once.
4. Acknowledges that physical exercise, including but not limited to boot camps, aerobic classes, martial arts, kickboxing, running, kung-fu, weight training, obstacle courses, and any other related sports or fitness activity, is an extreme test of one's mental and physical limits and carries with it inherent potential for damage or loss of property, serious injury and death. That the undersigned assumes all risks of participating in these types of events and activities including the inherent dangers 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.
5. The undersigned expressly waives, releases, discharges and agrees not to sue from any liability of death, disability, personal injury, or action of any kind Johnny Reed Enterprises, Hall County Adventure Boot Camp, Johnny Reed, Hall County Parks & Leisure Services, or their instructors, officers, affiliates, and executors for the undersigned participating in said sporting events and/or training for said sporting events.
6. The undersigned acknowledges that she has carefully read this "waiver and release" and fully understands that it is a release of liability. The undersigned expressly agrees to release and discharge Johnny Reed Enterprises, Hall County Adventure Boot Camp, Johnny Reed, and Hall County Parks & Leisure Services from any and all claims or causes of action and agrees to voluntarily give up or waive any right she may otherwise have to bring a legal action against the providers of Hall County Adventure Boot Camp for personal injury or property damage.
7. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence.
8. If any portion of this agreement and release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.
9. The undersigned agrees to follow and abide by the policies, procedures and rules of Hall County Adventure Boot Camp as outlined below, as well as any additional policies, procedures and rules which may be established by Johnny Reed Enterprises and Hall County Adventure Boot Camp for the conduct of its programs.
   
   Please check the following to indicate that you have read and agree to each of them.
   
    Fees are due at the time services are contracted. Services will not be provided until payment is received in full. Under no circumstances will a camper be allowed to attend camp without having submitted payment.
   
   Any action or behavior that, in the opinion of the instructor, produces a negative, disruptive or distracting atmosphere (i.e. foul language, chronic lateness, use of electronic devices, derogatory comments, aggressive actions, unwillingness to follow instructions, etc.) will not be tolerated. The person(s) responsible will be required to leave the class and only be allowed to return at the sole discretion of the instructor. Under such circumstances no refund or credit will be given for missed sessions regardless of how many are missed.
   
   Campers are expected to attend class everyday and be on time. There are no refunds or make-ups for missed days. A prorated credit towards a future camp may be issued if a camper, for reasons beyond their control, is unable to complete the one they originally joined. This credit is nontransferable. Camp fees can not be used towards any other product or service provided by Hall County Adventure Boot Camp or Johnny Reed Enterprises.
   
   Photos or video may be taken during the course of the camp and may be used for promotional purposes by Johnny Reed Enterprises and Hall County Adventure Boot Camp. By participating in the camp, campers give their consent and permission for such use of their image and likeness, and release all rights to these images. Individual "before & after" photos will not be used for any promotional purposes except with written authorization.
   
   Boot Camp classes are conducted in areas accessible to the general public.  It is each individual's responsibility to safeguard their own personal items.  Conceal valuable items and lock your vehicle.  Johnny Reed and Hall County Adventure Boot Camp can not be held liable for any lost, damaged, or stolen items.
   
   
   
10. The undersigned agrees that this is the full agreement between the parties, that the agreement can not be modified orally, that no representative of Johnny Reed Enterprises, Hall County Adventure Boot Camp, Hall County Parks & Leisure Services, nor anyone else has 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.

By submitting this form, I acknowledge that I have read and understood its content, have answered all questions truthfully and to the best of my ability, and agree to its provisions.