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Boot Camp Las Vegas Registration

Registration Form & Release

Thank you for registering for Boot Camp Las Vegas. 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. (If you are returning for a second session, just go to the payment page. No need to re-register!)
Required fields are marked in bold.

First Name 
   Last Name 
  Date of Birth:
 /  /  
Address:
   City:
State:
Zip:
Phone Number:
   Email Address: 
    Gender
Emergency Contact:
   Contact's Phone Number:
    
How Did You Find Us?
   (Optional) Who Referred You?
    
Fitness Level (1-10, 10 being best)   
   My Main Goal Is To:
  
Is This Your First Camp? 
   If No, Camp Attended:
  
First Class You Will Attend

(after the first day you can go to whichever time and location you want)
 
Date You Will Start:  
   Number of days per week (1-5):   
  
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 doctor's advice before beginning any health/fitness/nutrition program!
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
Medications:  		 
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
Medications: 
 
3. Do you have a seizure disorder (epilepsy)?  
4. Do you have diabetes adult or juvenile?
Medications:  		 
5. Have you ever been found to be anemic (low blood count)?  
6. Do you have high blood pressure (hypertension)?
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 athsma?
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. If you have had your body fat tested, what is you percent body fat?  %  
Click 'Submit', and go to the Release Form


Copyright 2011 Boot Camp Las Vegas.  All Rights Reserved.

CORPORATE OFFICE:
3753 HOWARD HUGHES PARKWAY
SUITE 200
LAS VEGAS, NV 89169
702-767-8797