Amelia Island Adventure Boot Camp Class
FREE BOOT CAMP REGISTRATION
Please check calendar for camp dates, times and locations before submitting form.
For Questions regarding the Free Camps please contact Karlena Barron at:
KBarron@ameliaislandbootcamp.com
Phone: (904) 237-0074
Amelia Island Adventure Boot Camp Medical History and Health Questionnaire Form
(Free Boot Camp Session)
Please fill this form out with complete accuracy – it is essential for your safety.
Name: __________________________ Age: _____ Sex______ Height_______
Address: ____________________________________________
City : _________________________ State: ______ Zip: ___________
Work Phone: ______________ Home Phone: _____________
Primary Email Address: ____________________
Occupation: __________________________________
Emergency Contact Name_______________ Emergency Contact Phone# ________________
Known Diagnosis, if any _________________________________________________________
Do you have or have you ever had: |
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NO |
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A Seizure Disorder (Epilepsy)? |
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Diabetes, Type I or Type II? |
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High Blood Pressure? |
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Heart Disease? |
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High Blood Cholesterol Level? |
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Asthma? |
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Severe or Any Neck Injury ?If Yes Explain
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Injured your back? If Yes Explain.
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Other Physical Conditions which cause pain? If yes Explain
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Knee Pain? If yes Explain
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Shoulder Pain? If Yes Explain.
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Please read the following consent/liability release form below:
I acknowledge 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. I, the undersigned, assume the risks of participating in these types of events/activities including the elements of a natural environment that I am fit, and I have a regular medical physician they can contact regarding any medical problems that they might develop. I, the undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Amelia Island Adventure Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.
Amelia Island Adventure Boot Camp shall not be liable for any injuries or damages to me, or subject to any claim , demand, injury or damages, whatsoever, including without limitation, those damages from acts of passive or active negligence on the part of Amelia Island Boot Camp their officers, employees, or agents. I do hearby expressly forever release and discharge Amelia Island Adventure Boot Camp from all such claims, demands, injuries, damages, actions, or causes of action. I acknowledge that I have carefully read this paragraph and fully understand that this is a waiver and release of liability. It is my responsibility to insure that I am physically able to participate in this program. Only a doctor can advise me on my ability to participate. By my signature below, I am acknowledging that I have been given the opportunity to obtain that advice and that I have been advised that I can participate.
_________________________/____/2007
(Signature and date)
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