Doylestown Adventure Boot Camp

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Address Street 1:

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Date of Birth:

I rate my current fitness level as:

I was referred by:

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This is my first camp:

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If you answered "No", when was the last camp you attended?

My main goal is:

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Which camp are you joining?:

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Medical History
(If you are a returning camper, only complete the sections that have changed.)



Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?	List Medications:
Do you take any prescribed medication on a permanent or semi-permanent basis?	List Medications:
Do you have a seizure disorder (epilepsy)?	List Medications:
Do you have diabetes (adult or juvenile)?
Have you ever been found to be anemic (low blood count)?
Do you have High Blood Pressure (hypertension)?	List Medications:
Do you have or have you ever had the following diseases?	Heart Disease
	Lung Disease
	Kidney Disease
	Liver Disease
Do you wear glasses or contact lenses?
Do you have asthma?	List Medications:
Do you currently smoke cigarettes?
Do you have an abnormal resting EKG?
Have you ever had a severe neck injury? Describe:
Have you ever been knocked out? Describe:
Have you had a broken bone or fracture in the past 2 years? Describe:
Do you have back pain?
Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:
Do you have other physical conditions which cause pain? Describe:
Detail any surgical procedures:
What are your goals for the next three months?
Have you had your body fat tested?	If yes, what percentage is it? %
Are you training for a specific event? If yes, explain:
Have you ever been under the guidance of a psychologist? If so, for what reason?:
Is there any other condition that Wendy Yazujian/Kathy DeMarco may deem as an unreasonable risk to client’s health?
Notice: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program! Release This release is entered into between the undersigned and Doylestown Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Doylestown. The purpose of Doylestown Adventure Boot Camp including Doylestown 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 Wendy Yazujian/Kathy DeMarco 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 Doylestown Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Wendy Yazujian/Kathy DeMarco including Doylestown 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 Doylestown 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 Doylestown Adventure Boot Camp including Wendy Yazujian/Kathy DeMarco 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, 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 Doylestown Adventure Boot Camp. I will remember to set my alarm and be at camp on time. I understand that diet and nutrition will affect my fitness goals and performance during boot camp. I will bring a positive attitude, and expect to have fun! Electronic Signature: Date: I agree to all Terms and Conditions listed above.

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