You will be notified to schedule your pre-camp evaluation (if needed for your program).
Name (First and Last)
Address
City
State
ZIP
Profession
Country
Date of Birth
Home Number
Cell Number
Work Number
Email Address
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
Indicate START DATE LOCATION Choose amount of days/price from the drop down menu.
(Northridge or Woodland Hills) the program you are joining?
5 days/week = $299 (M-F 5:30am Camp only)
4 days/week (M-Th 6pm Camp only)=$249
3 days/week (M-W-F 5:30am Camp only)= $199
3 days/week (T-Th-F 5:30am Camp only)= $199
Form of payment:
(After filling out this form you will be taken to a secure Pay Pal page to enter you credit card info.)
Check
Visa
Mastercard
American Express
Cash
MEDICAL HISTORY (If you are a returning camper, only complete the sections that have changed.)
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
Occassionally
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?
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!
RELEASE Customer client agrees to confidentiality with respect to San Fernando Valley Adventure Boot Camp and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of San Fernando Valley Adventure Boot Camp. The undersigned agrees to a non-compete within a 50 mile radius of Northridge, California for a period of 5 years from date of participation. Checkmark the following: Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence. 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. can not be used towards any other products or services provided by San Fernando Valley Adventure Boot Camp.
