Part 1: Personal Information
Personal Information:
First Name:
Last Name:
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Date of Birth:
Height: Weight:
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Job Title/Position:
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I rate my current fitness level as a... (Use scale 1 - 10, 10 being highest = elite athlete)
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0
1
2
3
4
5
6
7
8
9
10
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Physician Name:
Physician Phone:
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General Information:
How did you hear about boot camp?
If by Referral or Other:
Please Select...
VC Reporter
VC Star
Acorn
Car Window Decal
VC Newcomers Guide
Brochure
Flyer
Gift
Internet Search
Referral
Other...
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Contact Information:
Residence Address:
City:
State:
Zip Code:
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Home Phone:
Cell Phone:
Work Phone:
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Email Address:
Emergency Contact:
Emergency Contact Phone:
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Part 2: Program Options
Camp Details:
I am signing up for the following camp:
Camp date of interest:
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Ventura Boot Camp
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Please Select...
January 7 - January 25, 2013
February 4 - February 27, 2013
March 4 - March 22, 2013
April 1 - April 19, 2013
April 29 - May 24, 2013 4wk
June 3 - June 26, 2013
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NOTE:
Attendance Details:
Attendance Options for (must select one) All programs are 3 weeks @ 1hr/day; except May Camp which is 4 weeks.
5:30am Camp Only
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5 Days a week (M-F)
3 Days a week (M, W, F)
3 Days a week (Tu, Th, F)
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Please tell us which monthly payment plan you Intend to choose.
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Month to Month
3 Month Membership
12 Month Membership
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General Camp Details
This is my first camp:
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Yes
No
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If you've answered "no", when was the last camp you attended...
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Payment Details: (for month-to-month options only)
Payment Options (Must Select One)
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I will pay online using PAYPAL
I will mail a check or money order made out to True North Fitness
I will fax a Credit Card Authorization Form
I have a gift certificate to apply and sign will call to activate
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NOTE: All memberships are conveniently billed monthly with EFT/CC
PART 3 Medical & Exercise History
Confidentiality & Privacy Policy:
NOTE: All "YES" answers require a written explanation in the box below Otherwise your registration is incomplete.
Q1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? If yes,please describe below.
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Q2. Do you take any prescribed medication on a permanent or semi-permanent basis? If yes,please describe below.
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Q3. Do you have a seizure disorder (epilepsy)?
Q4. Do you have diabetes Type I (IDDM) or Type II (NIDM)?
Q5. Have you ever been found to be anemic (low blood count)?
Q6. Do you have High Blood Pressure (hypertension)?
Q7. Do you have or have you ever had the following diseases?
Heart Disease
Lung Disease
Kidney Disease
Liver Disease
Q8. Do you have or have you ever had asthma?
Q9. Have you ever had a severe neck injury?
Q10. Have you ever been knocked out?
Q11. Have you had a broken bone or fracture in the past 2 years?
Q12. Have you ever had a stress fracture or shin splints before?
Q13. Have you ever injured your back?
Q14. Do you have back pain?
Please Select...
Never
Seldom
Occasionally
Frequently with vigorous exercise or heavy lifting
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Q15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
Q16. Do you have other physical conditions which cause pain?
Q17. Have you had any surgical procedures?
Q18. Do you smoke?
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Q19. Have you ever smoked?
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Q20. Are you currently on a "diet", enrolled in a weight loss program, or
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Q21. What are your goals for the next three months?
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Q22. Have you had your body fat tested?
Q23. Do you have ANY physical limitations that restrict your ability to exercise or to execute normal, functional movements? Or has a medical professional ever directed you to limit your exercise, or that you not participate in an exercise program which is not directly administered by a medical professional?
Q24. Are you training for a specific event?
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Required Written Explanations (if any)
Please Explain Any Other “Yes” responses not already explained. Please Reference The Question Number.
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Other Prior Exercise/Sports History & Experiences
Please Describe Any Prior Exercise/Sports History & Experiences [Good & Bad]
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NOTE: If you are unsure about the definition of any terms in this form, or of your ability to participate in this program, please call us first to clarify. Do not assume and DO NOT REGISTER; regardless of cause any cancelled registrations will incur a $55 dollar cancellation fee.
Part 4: Participation Agreement, Informed Consent Waiver, And Liability Release & Noncompete Agreement
Please Read:
This agreement is entered into willingly by me, an individual, and the entities or persons listed below in section (A) on account of my desire to participate in a voluntary fitness program. I affirm my understanding that this fitness program is an extreme test of a person's physical and mental limits and carries with it the potential for serious injury, death, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, personal health condition, lack of hydration, inadequate nourishment, equipment, vehicular traffic, and actions of other people including, but not limited to, participants, spectators, or trainers. I hereby assume all risks of participating in this activity. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault. In consideration of my application and permitting me to participate in the Adventure Boot Camp program, I hereby take action for myself, my executors, administrators, next of kin, successors, and assigns as follows:
Waive, Release, and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me including my traveling to and from Boot Camp training, THE FOLLOWING ENTITIES OR PERSONS:
True North Pioneering, Inc., Ventura County Adventure Boot Camp, the City of San Buena ventura, the City of Camarillo, the City of Thousand Oaks, the County of Ventura, Ventura Parks Department, Camarillo Parks Department, Thousand Oaks Parks Department, the State of California Parks Department, and Ventura Unified School District, and their instructors, officers, affiliates, employees, agents, board members, and executors
Indemnify and Hold Harmless the entities or persons mentioned in the above paragraph from any and all liabilities or claims made as a result of participation in this event, whether caused by the negligence of releases or otherwise.
I understand the purpose of the Adventure Boot Camp Program offered by True North Pioneering, Inc. 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 and assistant coaches are not physicians and are not trained in any way to provide medical diagnosis or any other type of medical advice.
Acknowledges that coaching/training provided by True North Fitness & Health is designed to help increase health and fitness and Adventure Boot Camp is another tool for teaching athletes/individuals about themselves, and True North Fitness does not guarantee any specific fitness or health results by my participation.
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 their training, or otherwise, that they should stop the training session and should contact a physician at once.
Acknowledges that they are fit, do not have a physical injury or condition that would preclude participation in regular vigorous exercise and have not been advised otherwise by a qualified medical person, and they have a regular medical physician they can contact regarding any medical problems that they might develop.
Acknowledges I am asking to participate in this progressive fitness program strictly for personal reasons to improve my fitness conditioning and acknowledge that as a result I will be exposed to the proprietary training techniques of Adventure Boot Camp which are intended for same; consequently, I acknowledge I am not a trained or certified fitness professional, and agree that I am not authorized to record the programming or daily plans of Adventure Boot Camp, and I willingly surrender and promise that, for a period of no less than 24 months afterward, I will not directly or indirectly participate in a business that is similar in nature and in the same geographic area (within a radius of 50 miles) of any Adventure Boot Camp. This includes participating in my own business or as a co-owner, director, officer, consultant, independent contractor, employee or agent of another business.
Acknowledges that this Accident Waiver and Release of Liability form will be used by Adventure Boot Camp, in which the undersigned chooses to participate, and that it will govern my actions and responsibilities at during my activities with the Boot Camp.
I hereby consent to receive medical treatment, which may be deemed advisable in the event of injury, accident and/or illness during my Boot Camp training.
Notice:
By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death. I also understand that I may stop any training session at anytime. By signing this document, I assume all risk for my health and well being and any resultant injury or mishap that may affect my well being or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures.
Please make a selection. Please check if you accept these terms. You will be asked to sign acknowledgement at your evaluation.
Part 5: Performance Pledge
Please Read:
In the spirit of harnessing your best effort and optimizing your results from Adventure BootCamp (as stated in the "What you can Expect" statistics), we have established the following personal performance pledges. This agreement is by and between you and yourself. Your greatest results will be achieved by following these edicts. Your choice to break any performance promises is breaking a promise to yourself, moves you away from your stated goals, and WILL result in other than best results. In excessive cases, it will cause other than favorable results such as fat mass gain, body composition increase, or lean mass loss. If you have genuine concern about being able to follow any of these promises, please contact us for additional lifestyle coaching services so we can supplement your program and work together to optimize your efforts and move you toward your performance goals!!
Click each of the following:
Please make a selection. I agree that I will abstain from [not consume] alcohol during my Boot Camp period.
Please make a selection. I agree to abstain from the use of foul language during Boot Camp.
Please make a selection. I agree to abstain from eating or speaking the words Twinkie, Donuts, Cookies, potato chips, Brownie, Ho-Ho's, Ding Dong, or Cake during the course of Boot Camp.
Please make a selection. 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.
Please make a selection. I will arrive at camp ON TIME. [I will set 4 or more alarms as necessary to ensure.] (Any violation of the above statements will result in twenty push-ups per occurrence.)
Please make a selection. 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 and I provide my release for same. I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization.
Please make a selection. I understand there is no refund policy, but I can receive a credit for my unused portion of camp towards a future camp if, for reasons beyond my control, I am not able to complete the one I originally joined. I understand that absences cannot be recouped or made up. Camp credits may not be used towards any other products or services provided by True North Pioneering, Inc.
Please make a selection. I understand that I may only attend the class I am registered in.
Please make a selection. I will follow proper dietary practices as explained by the VABC instructors.
Please make a selection. I have read and fully accept the Ventura Adventure Boot Camp Program Policies and Guidelines .
Submit your registration:
Your signature will be required at the time of your evaluation and you agree to the terms now by clicking the SUBMIT REGISTRATION BUTTON below!
By submitting this form, you are agreeing to all the above!
After submitting your registration you will be redirected for ONLINE PAYMENT
NOTE: Your registration will be confirmed only after receipt of payment. Space is limited and classes sell out, so to secure your place in camp please submit your payment immediately.
If paying by check, please make checks payable to True North Fitness, and mail it to:
Ventura County Adventure Boot Camp
