Star City Adventure Boot Camp for Women

Boot Camp Registration

Star City Adventure Boot Camp Class
REGISTRATION

You now have 2 options:
A. You can print this form and send it in with payment by mail
B. Register Online
Fill out the online form below to register via internet. Click on Submit to go to the payment page.
Payment Page: Pay via Paypal. Choose your class and finish your online registration

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

If paying by check, please make check out to:
Star City Adventure Boot Camp
16540 Bauman Circle
Omaha, NE 68116
jody@starcitybootcamp.com
Phone: (402) 213-1462

If you chose option A: Print this page and mail it in.

If you choose option B, please fill out the form below and click Submit . . . I am ready to get fit!"

You will be notified to schedule your pre-camp evaluation (if needed for your program).
Name
Address
City
State
ZIP
Profession
Date of Birth	(mm/dd/yyyy)
Phone Number		Work Number
Email Address
I rate my current fitness level as a (1-10), ten being high.
I was referred by:
How did you hear about us?:		Please specify publication / website / friend or other referral:
This is my first camp:	Yes \| No	If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number
What is the Event Name (from the Calendar) & which amount of days are you joining?

Form of payment:		T-Shirt Size:
If paying by check, please make payable to: Star City Adventure Boot Camp 16540 Bauman Circle Omaha, NE 68116 jody@starcitybootcamp.com Phone: (402) 213-1462 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.)?
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
3. Do you have a seizure disorder (epilepsy)?
4. Do you have Adult or Juvenile diabetes?		List Medications:
5. Have you ever been found to be anemic (low blood count)?
6. Do you have High Blood Pressure (hypertension)?		List Medications:
7. Do you have or have you ever had the following diseases?
	Heart Disease:
	Lung Disease:
	Kidney Disease:
	Liver Disease:
8. Do you have asthma?		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?
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?		If yes, what percent is it?
20. Are you training for a specific event? If yes, explain:
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program! RELEASE This release is entered into between the undersigned and Star City Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Starcity. The purpose of Star City Boot Camp 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 Jody Berg is not a physician and is 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 Star City Boot Camp including Star City Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Star City Boot Camp including Star City 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, 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 Star City Adventure Boot Camp 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 Star City Boot Camp including Star City Adventure Boot Camp 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. Your signature will be required at the time of your evaluation and you agree to the terms now! ____________________ Signature ____________________ Printed Name ____________________ Date
I agree to all Terms and Conditions listed above

For More Information, Contact us at (402) 213-1462 or e-mail jody@starcitybootcamp.com