Fitness Bootcamp Registration Form Full Name: Birthday Age Gender Male Female Email Primary Phone Number Other Phone Number Emergency Contact Emergency Phone Which Boot Camp are you interested in? 4x4 Boot Camp 4x4 Boot Camp Plus** 2x4 Boot Camp 4x4 For Moms I rate my current fitness... (10 is high) 1 2 3 4 5 6 7 8 9 10 Is this your first bootcamp? Yes No How did you hear about us? Flyer List Server Email Friend Internet Other If other, explain. What are your biggest health and fitness challenges? What do you hope to accomplish from this bootcamp? How do you want to feel at the end? What are your goals in the next 3 months? What are your goals in the next 6 months? Medical History (Check all that apply) Chest Pain Shortness of Breath Dizziness Vascular Disease Diabetes Thyroid Problems Emphysema Asthma Heart Murmurs Heart Palpitations IF YOU CHECKED YES TO ANY OF THE ABOVE, PLEASE GET CLEARANCE FROM YOUR DOCTOR BEFORE STARTING ANY EXERCISE PROGRAM Do you have have high blood pressure? (140/90 or above) Yes No Do you have high cholesterol? (240 or higher) Yes No Do you smoke cigarettes? Yes No Is there a history of heart disease in your immediate family? Yes No Do you suffer from arthritis or joint pain? Yes No If yes, where? Do your knees hurt? Yes No Have you had knee pain that disabled you for more than 2 weeks anytime in the past 2 years? Yes No If yes, describe. Do you suffer from back pain? Yes No Do you have any other injuries we shoud be aware of? List any medications you are taking. Do you have any physical conditions which cause you pain? If yes, describe . Are you pregnant? Yes No By filling in your name in the box below you agree that: 1. You are entitled to attend 16 1-hour bootcamp training sessions 2. You do not have or are aware of any serious medical conditions that by starting an exercise program would be endangering your life or your health. 3. 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. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Aja Davis for the undersigned participating in said sporting events and/or training for said sporting events. 4. 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. 5. You need to bring a yoga/exercise mat and towel to each session. Wear comfortable clothes and good sneakers. 6. You will keep a record of your food for the duration of the camp and turn them into Aja Davis on a weekly basis. These forms will be given to you on the first day. 7. You will attend every session unless your absence is previously discussed with the instructor or excused by your doctor. 8. You will not whine, moan or complain about any exercise given. 20 push-ups per occurrence. 9. Twinkies, Cupcakes, The Cakeman2019s Red Velvet cake, ice cream will be off limits during the camp. 10. Come with a positive attitude and expect to have FUN! Type Full Name Here: **Payment for Bootcamp and Body By Brooklyn Spa will be made separately. Bootcamp is $249 (unless otherwise indicated by Aja). Once you have paid for Bootcamp you will receive a form on your first day of class that you can take to Body By Brooklyn to receive your discount.