BOOT CAMP REGISTRATION FORM AND RELEASE

Thank you for registering for the Tarrant County Boot Camp. If you are a returning camper, and you have attended camp within the last 6 months, and you have no changes in your contact information or medical status, you are eligible to complete the shorter
Re-enlistment Form. Otherwise please complete and submit the form below.

Once we have received your completed registration form and payment, we will send you a confirmation by email with additional information. (Remember: You may also purchase Tarrant County Boot Camp Gift Certificates for your friends and family.)

Tarrant County Boot Camp Registration Form

Name:

Address:

City:

Zip:

Home Phone

Cell Phone

Job Title

Work Phone

Date of Birth:

Confirm Email

Would you like to sign up for a FREE email fitness newsletter?

Yes my email address is listed above.

This is my first camp

Yes

No - Last date of camp attended:

Emergency Contact

Emergency Contact Phone

I rate my current fitness level as a
(use scale of 1-10, 10 being highest = elite athlete)

How did you hear about boot camp?

If by Referral, Boot Camper or Other, please specify:

Camp Information

Boot Camp Start Date:

Number of days per week:

5 days per week (for 5 weeks) $374

3 days per week (for 5 weeks) * $249

5 days per week (for 4 weeks) $299

3 days per week (for 4 weeks) * $199

Express Camp 5 days per week (for 3 weeks) $225

Express Camp 3 days per week (for 3 weeks)$150

Express Camp 5 days per week (for 2 weeks) $149

Express Camp 3 days per week (for 2 weeks)$99

*We prefer that you attend M,W,F of each week. Exceptions can be made if you let us know ahead of time. Most women decide to add days after enrolling in the 3-day program.

Payment Options (check one)

	I will pay online using my credit card
	Check or money order (made out to Tarrant County Boot Camp)

Medical History

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!
All “YES” answers require a written explanation below		Yes	No
1.	Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2.	Do you take any prescribed medication on a permanent or semi-permanent basis?
3.	Do you have a seizure disorder (epilepsy)?
4.	Do you have diabetes (adult or juvenile)? List medications:
5.	Have you ever been found to be anemic (low blood count)?
6.	Do you have High Blood Pressure (hypertension)? List medications:
7.	Do you have or have you ever had the following diseases?
	Heart Disease
	Lung Disease
	Kidney Disease
	Liver Disease
8.	Do you have or have you ever had asthma? List medications:
9.	Have you ever had a severe neck injury? Describe:
10.	Have you ever been knocked unconcious? Describe:
11.	Do you wear glasses or contact lenses?
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.	Have you had any surgical procedures?
18.	What are your goals for the next three months?
19.	Have you had your body fat tested?
20.	Are you training for a specific event? If yes , describe:
If you are unsure about the definition of any terms in this form, please call us to clarify. Do not assume. PLEASE EXPLAIN ALL “YES” ANSWERS BELOW. PLEASE REFERENCE THE QUESTION NUMBER.

Informed Consent Waiver, Release and Hold Harmless Agreement

This waiver and release is entered into between the undersigned and Tarrant County Boot Camp, its instructors, officers, affiliates, and executors, in addition to the City of Arlington, the City of North Richland Hills, and the County of Tarrant.

The purpose of the Boot Camp Program 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 agree to the following:

Acknowledges that the instructor is not a physician and is not trained in any way to provide medical diagnosis or any other type of medical advice.
Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but Tarrant County Boot Camp does not guarantee neither good nor bad will occur, nor guarantees the training advice given by Tarrant County Boot Camp or its instructors will produce good nor bad results.
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.
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 and activities, 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 Tarrant County Boot Camp, its instructors, officers, affiliates, and executors 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 no representatives of Tarrant County Boot Camp, 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.

Click each of the following:

I agree that I will not consume alcohol during the month of Boot Camp.

I agree not to use foul language during Boot Camp.

I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp.

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.

I will arrive at camp ON TIME.

Any violation of the above statements 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 cannot be used towards any other products or services provided by Tarrant County Boot Camp.

Your signature will be required at the time of your evaluation and you agree to the terms now!

By submitting this form, you are agreeing to all the above!

NOTE: Please read the payment instructions below, before submitting your application.
You will receive a confirmation by email, once your application has been successfully submitted.

PAYMENT INSTRUCTIONS:

If you are paying by credit card, you will automatically be redirected to the Online Payment page to complete your registration.

If you are paying by check, please, only submit your application. DO NOT complete the Online Payment Form. Hit the <Back> button on your browser to return to this page, and complete the mailing instructions below.

Please make checks payable to Tarrant County Boot Camp, and mail it to:

Tarrant County Boot Camp
1702 Wild Rose Way
Southlake, Texas 76092

NOTE: Your registration will be confirmed only after receipt of payment. Space is limited, so please submit your payment immediately.