Personal Information
Participant Full Name
Billing Address
City
State
ZIP (Billing )
Profession
Country
Date of Birth
Phone Number (Billing )
Cell Phone Number - *Required for notification*
Work Number
Primary Email Address
Self Assessment & Additional Information
I rate my current fitness level as a (1-10), ten being high.
1 - Low
2
3
4
5
6
7
8
9
10 - High
I was referred by:
How did you hear about us?:
Please specify publication / website / friend or other referral:
This is my first camp:
If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number
Camp and Payment Information
What camp are you joining?camp calendar for availability
What time are you attending?camp calendar for availability
5:30 am
9:30 am
Choose your camp frequency and cost. camp calendar for availability.
*Cannot be combined with any other offer, not available on 2 or 3 week camp sessions.
Camp C1-12
Camp C4-12
Camp C5-12
Camp C6-12
Camp C7-12
Camp C8-12
Camp C9-12
Camp C11-12
1 Week FREE - Only $225 should you stay on board after your trial
Form of payment:
Please note: We no longer accept checks for payment.
Visa
Mastercard
Gift Certificate
Please note: The "Express" Camp option is only available when specifically offered on the Calendar page.
Credit Card Information
For security reasons, your credit card information is not stored or saved within our system. Your credit card information will be entered after your complete this screen. Please provide correct billing address and phone.
Credit Card Merchant Services
Credit Card Information is Required for registration.
MEDICAL HISTORY (If you are a returning camper, only complete the sections that have changed.)
Medical History
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
Yes
No
List Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
Yes
No
List Medications:
3. Do you have a seizure disorder (epilepsy)?
Yes
No
List Medications:
4. Do you have diabetes Adult or Juvenile?
Yes
No
5. Have you ever been found to be anemic (low blood count)?
Yes
No
6. Do you have High Blood Pressure (hypertension)?
Yes
No
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease:
Yes
No
Lung Disease:
Yes
No
Kidney Disease:
Yes
No
Liver Disease:
Yes
No
8. Do you have asthma?
Yes
No
List Medications:
9. Have you ever had a severe neck injury?
Describe:
10. Have you ever been knocked out?
Describe:
11. Do you wear glasses or contact lenses?
Yes
No
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
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. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat tested?
Yes
No
If yes, what percent is it?
20. Are you training for a specific event?
Release
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!
This release is entered into between the undersigned and Prime Physique, LLC.. DBA San Jose Adventure Boot Camp for Women, its officers, subsidiaries, affiliates, and executors in addition to the City of Campbell, San Jose, Santa Clara County and/or Campbell Parks and Recreation Department. The purpose of San Jose Adventure Boot Camp for Women is to provide fitness instruction and coaching for various levels of athletes/individuals.
The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:
1. Acknowledges that Brett A. Riesenhuber and staff are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that San Jose Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Brett A. Riesenhuber including San Jose Adventure Boot Camp will produce good nor bad results.
3. 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.
4. 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/activities including the elements of a natural environment, 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 San Jose Adventure Boot Camp for Women 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 San Jose Adventure Boot Camp for Women including Brett Riesenhuber nor anyone else has not 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.
Customer client agrees to confidentiality with respect to San Jose Adventure Boot Camp for Women and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of San Jose Adventure Boot Camp for Women. The undersigned agrees to a non-compete within a 50 mile radius of San Jose, California for a period of 5 years from date of participation.
Agreement and Signature
Additional Terms and Conditions by clicking here . By checking the box and clicking the "Submit" button below, you hereby represent that you have read the Additional Terms and Conditions in its entirety and you specifically acknowledge and agree to be bound by its contents.
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