North Atlanta Adventure Boot Camp - Fitness - Rosa Hurst, Instructor
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Boot Camp Registration Form & Release

Thank you for registering for the North Atlanta Boot Camp. Please complete and submit the form below. Once we have received your completed registration form and payment, we will send you a confirmation by email with additional information. (You may also purchase a North Atlanta Boot Camp gift certificate for someone else.)

North Atlanta Boot Camp Registration Form
Full name:
Address:
City:
Zip:
Profession:
Date of birth:
Home phone:
Cell phone:
Work phone:
Fax number:
E-mail address:
Would you like to sign up for a FREE email fitness newsletter?
Yes, my email address is listed above.
No
Camp date: 4
ATL = Piedmont Park  ALPH = Alpharetta  BC = Big Creek  FAIR = Fairgrounds   MARI = Marietta  MASH = Mashburn  MENs = Men's Camp
NF = North Forsyth  SPRNGS = Dunwoody/Sandy Springs SUW = Suwanee 
Camp time :

5:15am / 5:30am (ALPH, BC, MASH, MARI, NF, SPRNGS, SUW, MENs)
6:00am / 6:00pm( PIEDMONT only)
 6:15pm (ALPH, FAIR, MENs)
Number of days per week:
4 WEEK CAMPS:
           5 days / week $299
           4 days /week $239
           3 days /week $199
2 1/ 2 WEEK CAMPS:
           5 days per week $199
1 WEEK ADVANCED CAMPS:
(REPEAT CAMPERS ONLY!!!)
           5 days per week $79
This is my first camp:
Yes
No, last camp attended (Month - Location):
Emergency contact:    Phone:
I rate my current
fitness level as a:		 (1-10), 10 being high
I was referred by:
How did you first hear about us? (Please be specific.)


Specifics:
My main goal is to:
Comments:

MEDICAL HISTORY

If you are returning and have no medical changes, the medical section below does not need to be completed. All agreements remain the same. NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

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)? Yes No
4. Do you have diabetes adult or juvenile? Yes No
     List medications:
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    Occasionally    Frequently with vigorous exercise or heavy lifting
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?  

RELEASE

This release is entered into between the undersigned and North Atlanta Boot Camp/Bellana Fitness LLC. The purpose of North Atlanta Boot Camp/Bellana Fitness LLC 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 Rosa Hurst 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 North Atlanta Boot Camp/Bellana Fitness LLC does not guarantee neither good nor bad will occur nor guarantees the training advice given by North Atlanta Boot Camp/Bellana Fitness LLC 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 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 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 and North Atlanta Boot Camp/Bellana Fitness LLC 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 North Atlanta Boot Camp/Bellana Fitness LLC, 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.

Check the following:

I agree that I will not consume alcohol during the month of Boot Camp. Any violation will result in twenty push-ups per occurrence.
I agree not to use foul language during 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 Boot Camp every day unless it is an excused absence from my doctor or pre-approved with 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 (due to injury or major illness). Camp fees cannot be used towards any other products or services provided by Iron Ballet
I will remember to set my alarm and be at camp on time.

Your signature will be required at the time of your evaluation, and you agree to the terms now!

PAYMENT

Your registration will be confirmed only after receipt of payment. Space is limited, so please submit your payment immediately.
    Please select your payment method:
Paying online with credit card.
Mailing check.

By submitting this form, you are agreeing to the terms above!

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For more information call 404-978-5362 or write to info@bellanafitness.com.