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Please fill in the form clearly and completely. |
| PERSONAL INFORMATION: |
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First Name: |
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| Last Name: |
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| Address: |
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| City: |
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| State: |
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Zip: |
| Phone: |
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Fax: |
| E-mail: |
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| Profession: |
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| Date of Birth : |
Month: Day: Year: |
| This is my first camp: |
Yes |
No |
If no, when was the last camp and location
you attended? |
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| Which Camp will you attend |
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| Which Location? |
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| EMERGENCY CONTACT: |
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Name: |
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| Phone: |
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| I rate my current fitness level as a: |
(1-10, ten being high) |
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| I was referred by: |
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| My main goal is to: |
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| What was your search word, or how did you find us? (Please be specific. Thanks!) |
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| MEDICAL HISTORY: |
If you are returning and have no medical changes, the section below does not need to be completed.
All agreements remain the same. |
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| 1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? Please list |
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| 2. Do you take any prescribed medication on a permanent or semi-permanent basis? |
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| 3. Do you have a seizure disorder (epilepsy)? Yes No |
| 4. Do you have diabetes Adult or Juvenile? Yes No |
| Please List Medications: |
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| 5. Have you ever been found to be anemic (low blood count)? Yes No |
| 6. Do you have High Blood Pressure (hypertension)? Yes No |
| Please List Medications: |
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| 7. Do you have or have you ever had the following diseases? |
Heart Disease: Yes No
Lung Disease: Yes No
Kidney Disease:Yes No
Liver Disease: Yes No
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| 8. Do you have asthma? Yes No |
| Please 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 |
| 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? with vigorous exercise or heavy lifting |
| 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 / If yes, what percent is it? |
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| 20. Are you training for a specific event? |
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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 Atlanta Adventure Boot Camp. The purpose of Adventure Boot
Camp is to provide fitness instruction and coaching to 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 Mamadou Diakite 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 Mamadou Diakite does not guarantee neither good nor bad will occur nor guarantees the training advice given by Mamadou Diakite 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 inherent dangers of the natural elements, 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 and Andrew Alexander and Body Tamer 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 Mamadou Diakite, nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement freely and voluntarily without force or coercion.
All members MUST adhere to the following:
I agree that I will not consume alcohol during the month of Boot Camp. Any violation will result in twenty push-ups per occurrence.
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 Mamadou Diakite.
I will remember to set my alarm and be at camp on time.
Your signature will be required at the time of your arrival on site.
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I agree
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