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Somers Boot Camp Registration

Westchester Somers 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. A PayPal account is not required to pay via PayPal.

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:
Westchester Somers Boot Camp
3 Bridge Lane
Somers, NY 10598
GetFit@WestchesterBootCamp.com
Phone: (914) 960-4494

If you choose option A, Print this page and mail it in with payment.
If you choose option B: Fill out the form below and Click on SUBMIT.

Registration Form
Personal Information
Name		Address
City		State / ZIP	/
Profession		Country
Date of Birth	(mm/dd/yyyy)	Phone Number
Cell Number		Fax Number
Email Address

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	\|

Camp and Payment Information
What camp are you joining?
Choose your camp frequency and cost.
Form of payment:

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.)?
List Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
List Medications:
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes Adult or Juvenile?
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?
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:

Release

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

This release is entered into between the undersigned and LiveWellGetFit, its officers, subsidiaries, affiliates, and executors in addition to the City of Bedminster. The purpose of LiveWellGetFit 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 Laura Powell 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 LiveWellGetFit does not guarantee neither good nor bad will occur nor guarantees the training advice given by Laura Powell including LiveWellGetFit 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 s, 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 LiveWellGetFit 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 LiveWellGetFit including Laura Powell 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.

Customer client agrees to confidentiality with respect to LiveWellGetFit and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of LiveWellGetFit. The undersigned agrees to a non-compete within a 50 mile radius of Bedminster for a period of 5 years from date of participation.

Checkmark the following:

I agree not to use foul language during . Any violation will result in twenty push-ups per occurrence.

I agree not to eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of . Any violation will result in twenty push-ups per occurrence.

I agree to show up for every day unless it is an excused absence from my doctor or pre-approved with 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 , 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 LiveWellGetFit.

I will remember to set my alarm and be at camp on time.

I understand that diet and nutrition will effect my fitness goals and performance during .

I will bring a positive attitude, and expect to have fun

I agree to all Terms and Conditions listed above

Signature, Date and SPAM Verification

Electronic Signature

Date (MM/DD/YYYY)

For More Information Contact Carla at (914) 960-4494 or e-mail GetFit@WestchesterBootCamp.com