Registration

Please select your camp start date:
[select* camp
“Scare off the Fat, October 22 – November 16, 2018”
“Healthy for the Holidays, November 26 – December 21, 2018”
]

Please select a morning or an evening session and your frequency:

Morning sessions:

[radio frequency default:1 “20 workouts at 5 days/week: 5:30 a.m. to 6:15 a.m. (Mon-Fri: $250)” ]
[radio frequency “12 workouts at 3 days/week: 5:30 a.m. to 6:15 a.m. (Mon/Wed/Fri: $179)” ]
[radio frequency “8 workouts at 2 days/week: 5:30 a.m. to 6:15 a.m. (Tue/Thurs: $129)” ]

Evening sessions:

[radio frequency “8 workouts at 2 nights/week: 5:30 p.m. to 6:15 p.m. (Mon/Wed): $149” ]

Note: All fields are required.
Form of payment:
[select* form_pf_payment
“PayPal / Credit Card”
“Cash/Check”
]

Personal Information

[text* yourname placeholder “Name”] [email* email placeholder “Email”]
[text* phone placeholder “Mobile Number”] [text* address placeholder “Address”]
[text* city placeholder “City”] [text* zip placeholder “Zip”]
[text* profession placeholder “Profession”] [text* dob placeholder “Date of Birth”]


Self Assessment & Additional Information

I rate my current fitness level as: (1-10):
[select* fitness_level “Select from drop down options:” “1 – Low” “2” “3” “4” “5 – Medium” “6” “7” “8” “9” “10 – High”]
Is this your first adventure boot camp:
[select* first_camp “Select from drop down options:” “Yes” “No”]
[text* last_camp placeholder “Last Camp attended:”] [text* main_goal placeholder “My Main goal is:”]
[text* referred placeholder “I was referred by:”] [text* howhear placeholder “How did you hear about us?”]
[text* emergency_contact placeholder “Name of Emergency Contact”] [text* emergency_phone placeholder “Emergency Phone Number”]


Medical History

Enter N/A for any section which is Not Applicable for you.
[text* allergic placeholder “Are you allergic to any medication? List medications:”] [text* prescribed_medications placeholder “Do you take any prescribed medication? List medications:”]
[text* epilepsy placeholder “Do you suffer from epilepsy? List medications:”] [text* anemic placeholder “Are you anemic? List medications:”]
[text* diabetes placeholder “Do you have Diabetes? List medications:”] [text* hypertension placeholder “Do you have High Blood Pressure? List medications:”]

Do you wear glasses or contact lenses?
[select* glasses “Select from drop down options:” “No” “Yes”]
Do you have Asthma?
[select* asthma “Select from drop down options:” “No” “Yes”]

[text* heart_disease placeholder “Do you have Heart Disease? List medications:”] [text* lung_disease placeholder “Do you have Lung Disease? List medications:”]
[text* kidney_disease placeholder “Do you have Kidney Disease? List medications:”] [text* liver_disease placeholder “Do you have Liver Disease? List medications:”]

[textarea* neck_injury placeholder “Have you ever had a severe neck injury? Describe:”]
[textarea* knocked_out placeholder “Have you ever been knocked out? Describe:”]
[textarea* broken_bone placeholder “Have you had a broken bone or fracture in the past 2 years? Describe:”]
[textarea* disabled placeholder “Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe: “]
[textarea* injured_back placeholder “Have you ever injured your back? Describe:”]
[textarea* current_pain placeholder “Describe any current pain you may be experiencing: Describe: “]
[textarea* physical_conditions placeholder “Do you have other physical conditions which cause pain? Describe: “]
[textarea* surgical_proceedures placeholder “Have you had any surgical procedures: Describe:”]
[textarea* goals placeholder “What are your goals for the next three months? Describe:”]
[textarea* body_fat placeholder “Have you had your body fat tested? Describe testing and results:”]
[textarea training_event placeholder “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 Adventure Boot Camp, LLC, its officers, subsidiaries, affiliates, and executors in addition to the City of Worcester. The purpose of Adventure Boot Camp, 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 Alexis Rougas-Ermilio 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 Adventure Boot Camp, LLC does not guarantee neither good nor bad will occur nor guarantees the training advice given by Alexis Rougas-Ermilio including Adventure Boot Camp, 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 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 Adventure Boot Camp, 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 Adventure Boot Camp, LLC including Alexis Rougas-Ermilio 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 Adventure Boot Camp, LLC and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of Adventure Boot Camp, LLC. The undersigned agrees to a non-compete within a 50 mile radius of Worcester for a period of 5 years from date of participation.

Agree to the following:

I understand that Adventure Boot Camp, LLC does not share my personal or medical information with any other parties without my consent.

I understand that payments must be made in full prior to the start of each program. Refunds and credits of the program cost are not available once the session begins. In case of severe illness or a serious event, Adventure Boot Camp, LLC will make special arrangements on a case by case basis.

I agree not to use foul language during Boot Camp. 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 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 my Boot Camp coach.

I understand there is a no refund policy, but I may receive a credit (for an unused portion of camp) towards a future camp if, for reasons beyond my control, I’m not able to complete the one I originally joined. If I expect to receive a credit, I must inform Alexis Rougas-Ermilio/Adventure Boot Camp, LLC. Camp fees can not be used towards any other products or services provided by Alexis Rougas-Ermilio/Adventure Boot Camp, LLC.
There is a $25 fee for returned checks.

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 will remember to set my alarm and be at camp on time and agree to show up for Boot Camp and will adhere to the late policy (explained on the first day of camp).

I understand that diet and nutrition will affect my fitness goals and performance during boot camp so I commit to eating clean foods and beverages that will accelerate my success. I agree to give 100% effort to my coach and myself at each class and I commit to myself to change my lifestyle for better health and fitness.
I will bring a positive attitude, and expect to have fun.

I agree to all Terms and Conditions:
[select* agree “Yes” “No”]

[recaptcha]

[submit “Submit Pre-Camp Evaluation”]
1
Adventure Boot Camp Registration
Adventure Boot Camp
coachalexis@charter.net
Camp Information
Camp: [camp]
Frequency: [frequency]
Payment: [form_pf_payment]

Personal Information
Name: [yourname]
Email:[email]
Phone Number:[phone]
Address: [address]
City:[city]
Zip: [zip]
Profession: [profession]
Date of Birth: [dob]

Self Assessment & Additional Information
I rate my current fitness level as: [fitness_level]
Is this your first adventure boot camp: [first_camp]
Last Camp attended: [last_camp]
My Main goal is: [main_goal]
I was referred by: [referred]
How did you hear about us? [howhear]
Name of Emergency Contact: [emergency_contact]
Emergency Phone Number: [emergency_phone]

Medical History
Are you allergic to any medication? List medications: [allergic]
Do you take any prescribed medication? List medications: [prescribed_medications]
Do you suffer from epilepsy? List medications: [epilepsy]
Are you anemic? List medications: [anemic]
Do you have Diabetes? List medications: [diabetes]
Do you have High Blood Pressure? List medications: [hypertension]
Do you wear glasses or contact lenses? [glasses]
Do you have Asthma? [asthma]
Do you have Heart Disease? List medications: [heart_disease]
Do you have Lung Disease? List medications: [lung_disease]
Do you have Kidney Disease? List medications: [kidney_disease]
Do you have Liver Disease? List medications: [liver_disease]

Have you ever had a severe neck injury? Describe:
[neck_injury]

Have you ever been knocked out? Describe:
[knocked_out]

Have you had a broken bone or fracture in the past 2 years? Describe:
[broken_bone]

Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:
[disabled]

Have you ever injured your back? Describe:
[injured_back]

Describe any current pain you may be experiencing: Describe:
[current_pain]

Do you have other physical conditions which cause pain? Describe:
[physical_conditions]

Have you had any surgical procedures: Describe:
[surgical_proceedures]

What are your goals for the next three months? Describe:
[goals]

Have you had your body fat tested? Describe testing and results:
[body_fat]

Are you training for a specific event? If yes, explain:
[training_event]

I agree to all Terms and Conditions: [agree]


This e-mail was sent from a contact form on Adventure Boot Camp (http://www.baystatebootcamp.com/)
Reply-To: [email]

1
Adventure Boot Camp Registration
Adventure Boot Camp
[email]
Welcome [yourname],

It is great to have you in our camp.

I will be in contact with you shortly to coordinate your pre-camp evaluation.

I look forward to talking to you as soon as possible.

Please complete your payment via PayPal at:

Thank you and Payments

Thank you,
Alexis

Adventure Boot Camp, LLC
15 Bellingham Road
Worcester, MA 01606
Tel: (508) 579-6064
E-mail: coachalexis@charter.net
Reply-To: coachalexis@charter.net

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