PLEASE CHOOSE ONLY ONE SELECTION FROM THE 3 CHOICES BELOW!

$219 (3 days/week)
Please select one...Kennedy Park - Women OnlyHilton Head Park - Women OnlySkyline Church - Co Ed
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$269 (4 days/week)
Please select one...Kennedy Park - Women OnlyHilton Head Park - Women OnlySkyline Church - Co Ed
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$299 (5 days/week)
Please select one...Kennedy Park - Women OnlyHilton Head Park - Women OnlySkyline Church - Co Ed
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You will be notified to schedule your pre-camp evaluation (if needed for your program).


(*) required entry

Name (*)

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Address (*)

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City (*)

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State (*)

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Zip Code (*)

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Profession

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Date of Birth (*)

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Home Phone (*)

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Work Phone

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Cell Phone (*)

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Email Address (*)

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I rate my current fitness level as a (1-10), ten being the highest. (*)
Please select one...1-Low2345678910-High
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How did you hear about us?
Please select one...FriendFamilyWebsiteFlyerNewspaperMagazineTelevisionRadioOther (Please enter below)
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If you selected Other, please let us know where.

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Is this your first Adventure Boot Camp? (*)
YesNo
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If no, when & where did you last attend an Adventure Boot Camp?

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What is your main goal or hope to accomplish? (*)

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Name of Emergency Contact (*)

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Emergency Contact Phone (*)

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How many days per week are you registering for? (*)
Please select one...3 days/wk-$1994 days/wk-$2595 days/wk-$299
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Form of Payment (*)
CheckVisaMasterCardAmerican ExpressCash
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If paying by check, please make payable to: Glaze Fitness 851 Jamacha Road El Cajon, CA 92019-3206 getfit@sandiegoadventurebootcamp.com Phone: (619) 588-7300


MEDICAL HISTORY (If you are a returning boot camper, only complete the sections that have changed.)

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? (*)
Yes No
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If Yes, list medications.

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2. Do you take any prescribed medication on a permanent or semi-permanent basis? (*)
Yes No
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If Yes, list medications.

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3. Do you have a seizure disorder (epilepsy)? (*)
Yes No
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If Yes, list medications.

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4. Do you have diabetes Adult or Juvenile? (*)
Yes No
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5. Have you ever been found to be anemic (low blood count)? (*)
Yes No
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6. Do you have High Blood Pressure (hypertension)? (*)
Yes No
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If Yes, list medications.

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7. Do you have or have you ever had the following diseases?

Heart Disease? (*)
Yes No
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Kidney Disease? (*)
Yes No
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Liver Disease? (*)
Yes No
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Lung Disease? (*)
Yes No
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8. Do you have asthma? (*)
Yes No
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If Yes, list medications.

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9. Have you ever had a severe neck injury? Describe: (*)

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10. Have you ever been knocked out? Describe: (*)

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11. Do you wear glasses or contact lenses? (*)
Yes No
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12. Have you had a broken bone or fracture in the past 2 years? Describe: (*)

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13. Have you ever injured your back? Describe: (*)

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14. Do you have back pain? (*)
Please select one...NeverSeldomOccasionallyFrequently
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15. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe: (*)

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16. Do you have other physical conditions which cause pain? Describe: (*)

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17. Detail any surgical procedures: (*)

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18. What are your goals for the next three months? (*)

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19. Have you had your body fat tested? (*)
Yes No
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If Yes, what percent is it?

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20. Are you training for a specific event? If yes, explain: (*)

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


RELEASE This release is entered into between the undersigned and San Diego Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of El Cajon. The purpose of San Diego Adventure Boot Camp 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 Jake Glaze 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 San Diego Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by San Diego Adventure Boot Camp 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 San Diego Adventure Boot Camp 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 San Diego Adventure Boot Camp 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.

Checkmark the following: (*)
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. Fees can not be used towards any other products or services provided by Glaze Fitness or San Diego Adventure Boot Camp including any future Adventure Boot Camp or Glaze Fitness 8 Week Fitness Challenges.
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 boot camp.
I will bring a positive attitude, and expect to have fun!
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The undersigned agrees to confidentiality with respect to San Diego Adventure Boot Camp (SDABC) and all services provided by same. Undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of SDABC. The undersigned agrees to non-compete within a 50 mile radius of SDABC for a period of 5 years from date of participation. Your acceptance constitutes a valid and binding Non-Disclosure Agreement and violation thereof will result in legal action. Your signature will be required at the time of your evaluation and you agree to the terms now!

Signature (*)

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Printed Name (*)

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Date (*)

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Terms & Conditions (*)
I agree to all Terms and Conditions listed above
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