Section 1: Client Information
Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Profession
Date of Birth * / MM / DD YYYY
Phone (Home) * - (###) - ### ####
Phone (Mobile) * - (###) - ### ####
Phone (Work) - (###) - ### ####
At what phone number do you prefer to be contacted?
Email *
Section 2: Boot Camp Info
Boot Camp Location/Time *
Boot Camp Date *
Choose an Option *
I rate my fitness level
This is my first camp Yes No
The last camp I attended was:

(if applicable)
The location of my last camp:

(if applicable)
My main goal is to:
I found out about your camp: *
T-Shirt Size (for free shirt) *
Section 3: Medical History
Allergic to medications? *
If yes, please explain.
Are you currently taking any medications *
Currently taking any medications? If yes, please explain.
Are you epileptic?
(Suffer from seizures?) *
Are you epileptic? Suffer from seizures? If so, when was the last one?
Are you diabetic? *
Are you diabetic? If so, is it controlled by insulin or medication?
Is your doctor currently prescribing drugs for your blood pressure or heart condition? *
If so, please explain.
Do you have or have you ever had any of the following diseases?
Heart Disease
Lung Disease
Kidney Disease
Liver Disease
Do you have asthma? *
Do you have back pain? *
If so, please explain
Have you ever had severe neck injury? *
If yes, please explain.
Do you suffer from any bone or joint problems? *
If so, please explain.
Do you have any other physical conditions that cause pain? *
If yes, please explain.
Please list any illnesses, hospitalizations, or surgical procedures in the last two years.
Are you training for a specific event? *
If yes, please describe the event.
Electronic Signature * First Last
Section 4: Terms * I agree that I will not consume alcohol during the boot camp. Any violation will result in twenty push-ups per occurrence. I agree to not use foul language during boot camp. Any violation will result in twenty push-ups per occurrence. I agree to not eat or say the words "Hushpuppies, Krispy Kreme donuts, frappucinos, french-fries, pizza, ice cream, Slurpees, chocolate bars, chips, pies, pastries, Ho-Ho's, Ding Dongs, or cupcakes" during the course of 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 a 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 cannot be used towards any other products or services provided by Pensacola Adventure Boot Camp. I will remember to set my alarm and be at camp on time. I will bring a positive attitude, and expect to have fun! I have read and agree to the Release Waiver.
Date * / MM / DD YYYY
What form of payment would you like to use? * Mail in payment Online credit card
How did you hear about Boot Camp? *
If other, please explain.

Section 1: Client Information

Section 2: Boot Camp Info

Section 3: Medical History

Do you have or have you ever had any of the following diseases?