Registration: Long Beach Running Boot Camp

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Running Boot Camp Registration
REGISTRATION

You now have 2 options:
A. You can Print this page and send it in with payment (Make payment to Fitness Through Motion) by mail to:
Fitness Through Motion
Attn: Running Boot Camp
P.O. Box 14351
Long Beach, CA 90853
info@LongBeachBootCamp.com
(562) 225-4181

B. Fill out the online form below to register online and then pay via PayPal.
Fill out the form below and click on SUBMIT...
You will be taken to the payment page, where you can pay Via Paypal.

NOTE: We cannot guarantee your space will be reserved if you do not supply us with payment information on this form if sending via internet.

Registration Form
Veterans: (People who have taken class before), fill out top portion of registration only. Fill out Health History only if things have changed. Space is limited to 30 runners.
Personal Information
Name
Address
City
State / ZIP	/
Profession
Country
Date of Birth	(mm/dd/yyyy)
Phone Number
Work Number
Fax Number
Email Address
T-Shirt Size	(Men's sizes only-for comfort reasons)

Self Assessment & Additional Information
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:

If you answered "no", when was the last camp you attended:

My Main goal is:

Name of Emergency Contact & Phone Number
	\|
If you are paying via PayPal, please provide your PayPal email address, so we can match your Registration with your Payment and confirm your spot. (If not paying by PayPal, please continue with registration form)
	(PayPal Email Address)

Camp and Payment Information
What camp are you joining?

What time are you attending?

Choose your camp frequency and cost.*

Form of payment:

That's only $10.83/day. I can't wait to start my running program. *COMBO means 3 Days/Week M, W, F (Running Boot Camp), 2 Days/Week T, TH ( Boot Camp)

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 diabetes Adult or Juvenile?

5. Have you ever been found to be anemic (low blood count)?

6. Do you have High Blood Pressure (hypertension)?

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?

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?

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:

21. Please add any other information you would like for us to know about you.

Release
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 Fitness Through Motion, its officers, subsidiaries, affiliates, and executors in addition to the City of Long Beach and the Los Angeles County . The purpose of Ftiness Through Motion including Long Beach Adventure Boot Camp and Running 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 Shawdee Ghavimi, Shannon Paul and Caroline Fiegen are not physician's 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 Fitness Through Motion including Long Beach Adventure Boot Camp and Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Fitness Through Motion including Long Beach Adventure Boot Camp and 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 Long Beach 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 Fitness Through Motion including Long Beach Adventure Boot Camp and 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.
Checkmark the following:
	I agree not to use foul language during Running Boot Camp. Any violation will result in twenty push-ups per occurrence.
	I agree not eat or say the words 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.
	I agree to show up for Running Boot Camp every day unless it is an excused absence from my doctor or pre-approved with the Running Boot Camp directors. Any violation will result in twenty push-ups per occurrence.
	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. I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization.
	I understand there is no refund policy, but I can receive a credit (for unused portion of camp) towards a future camp if I'm not able to complete the one I originally joined. Camp fees can not be used towards any other products or services provided by Fitness Through Motion including Long Beach Adventure Boot Camp.
	I will remember to set my alarm and be at camp on time.
	I understand that I need a pair of new running shoes for this program, so that I do not injure myself (shoes must be replaced after 6 mo of use).
	I understand that diet and nutrition will effect my fitness goals and performance during boot camp.
	I will bring a positive attitude, and expect to have fun!

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)