State:

Zip Code:

Profession:

Date of Birth:

Gender:
Male Female

Home Phone:

Work Phone:

Cell Phone:

E-Mail:

I currently rate my fitness level as a: (10 being best):
1 2 3 4 5 6 7 8 9 10

My main goal is to:

How did you hear about Boot Camps for LIfe?
Street Sign Post Card Internet Search Friend
If you answered "friend", please list your friend's name:

Emergency contact name

Emergency contact phone

Personal Medical History

1) Do you have ANY medical conditions that would prevent you from participating in exercise?
Yes No

If yes, please list and describe

2) Have you ever had an injury that would prevent you from participating in exercise?
Yes No

If yes, please list and describe

NOTICE: It is wise to seek your doctor's advice before beginning ANY health/fitness/nutrition program!

3) If you answered yes to either of the two questions above, do you have your physician's authorization to participate in this program?
Yes No NA

If you answered yes to 1 or 2 AND no to question 3, we can not allow you to participate until you recieve a medical clearance.