Please complete the Primary Information and Medical History forms below
and confirm you have reviewed the Waiver.

When complete, push the Submit button and we will review your application and contact you.

Primary Information

* Marked Fields are Required
* Name:
* Date of Birth:
* Home Address:
* City & State:
* ZIP:
* Phone:
Work Phone:
* Email:
Fax:
* Emergency Contact Name:
* Emergency Contact Phone:
* Camp Site:
* Rate Current Fitness Level:
Referred By:
* Form of Payment:
	Please Send Payments To: Fitness Bootcamp Inc. P.O. Box 1936 North Little Rock, Arkansas. 72115 501-765-5425

Medical History


* Are you allergic to any medication?
* Do you take any prescribed medication?
* Do you have any seizure disorders (epilepsy)?
* Do you have diabetes?
* Are you anemic (low blood count)?
* Do you have high blood pressure (hypertension)?
* Have you heart, lung, liver, kidney, disease?
* Do you have asthma?
* Have you suffered from a severe neck injury?
* Have you ever been knocked out?
If you said yes to any of the above, please describe:
* Do you wear glasses or contacts?
* Have you had any broken bones or fracture in the past 2 years?
If you said yes to any of the above, please describe:
* Any back injury?
If yes, please describe:
* Any back pain?
* Any knee pain in the past 2 years?
* Any physical conditions which cause pain?
* Any surgical procedures?
If you said yes to any of the above, please describe:

Waiver & Release

This Waiver and Release is entered into between the undersigned and Fitness Boot Camp, Inc. its officers, trainers, affiliates, executors in addition to the City of Little Rock, North Little Rock, and all others private and public locations for camps. The purpose of Fitness Boot camp Inc is to provide fitness instruction and coaching for various levels of Athletes/Individuals. The undersigned here by acknowledge that the following was explained to me and/or agree to the following. 1. Acknowledge that the officers, trainers, executors are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice. 2. Acknowledge that coaching/training is another tool for teaching/athletes/individuals about themselves, but the Fitness Boot Camp, Inc. does not guarantee neither good nor bad will occur nor guarantee the training advice given by Fitness Boot Camp, Inc. will produce good nor bad results. 3. Acknowledge 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. Videography and photography may be taken at campus which may appear on TV, web video, print or any other digital format when possible camp participants will told in advance of the days in which any photography or videography will be done. 5. Acknowledges that Boot camp classes running obstacle courses, and any other related sports are and extreme test of ones 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 inherent dangers of the natural elements that they are fit and they have a regular medical physician they can contact regarding any medical problems that might develop. The undersigned the expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind and Fitness Boot camp Inc for the undersigned participating in said sporting events or training. 6. The undersigned agrees that this is the full agreement between the parties, that Fitness Boot Camp, Inc. nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement and voluntarily without force or coercion.

	I Agree to show up for boot camp every day unless it is excused absence from my doctor or pre-approved with boot camp directors.
	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 if am not able to complete the one I originally joined, pending space availability.
	I will be on time

(BY SUBMITTING THIS FORM YOU ARE AGREEING TO ALL THE ABOVE!)