Fitness woman, register today, women fitness training, women's health, body in motion, fitness womanEast County

Adventure Boot Camp Registration and Payment

East County San Diego Adventure Boot Camp Class
REGISTRATION

You have 2 options:
A. You can print this form and send it in with payment by mail.
B. Pay via secure webpage over the internet, then fill out and submit the online form below.

**IF YOU PAY BY CREDIT/DEBIT CARD, THIS IS A 2 STEP PROCESS! First you click on the card logos below. A new window will open and you will be taken to your secure shopping cart where you can select the program and options you wish to participate in and pay with your credit or debit card. Once the transaction is complete, close that window (not your browser, just the payment window) and complete the Registration and Infromation form below. Be sure to answer all of the questions. When done, be sure to click on the "Submit...I'm Ready To Get Fit" button.

Click here to pay by credit or debit card

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

If paying by check, please make check out to:
Glaze Fitness
851 Jamacha Road
El Cajon, CA 92019-3206
getfit@eastcountyadventurebootcamp.com
Phone: (619) 588-7300

If you chose option A: Fill out the form below and click Submit..I'm Ready to get fit!.

$299 (5 days/week)	$199 (3 days/week)
Please select your park location	Please select your park location
SIX WEEK OPTION ONLY - July 14th - August 22nd
$448.00 (5 days/week) Please select your time	$298.00 (3 days/week) Please select your time
Also Available: Personal Training by appointment. For more information call (619) 588-7300 or e-mail us at getfit@glazefitness.com

If you choose option B, please fill out the form below and click Submit . . . I am ready to get fit!

You will be notified to schedule your pre-camp evaluation (if needed for your program).

Name

Address

City

State

ZIP

Profession

Date of Birth

(mm/dd/yyyy)

Phone Number

Work Number

Fax Number

Email Address

I rate my current fitness level as a (1-10), ten being high.

I was referred by:

How did you hear about us?:

Please specify publication / website / friend or other referral:

This is my first camp:

Yes No

If you answered "no", when was the last camp you attended:

My Main goal is:

Name of Emergency Contact & Phone Number

Please select from the drop down below, which amount of days are you joining?

Form of payment:

$299 (5 days/week) | *$199 (3 days/week) *This option is for those who have other commitments in the early a.m. Since it is only a 4-week class, we do prefer you to attend the full 5-day a week program for best results and overall work-out! You can do it!!

Address
City
State
ZIP

If paying by check, please make payable to:
Glaze Fitness
851 Jamacha Road
El Cajon, CA 92019-3206
getfit@eastcountyadventurebootcamp.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.)?

List Medications:

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

List Medications:

3. Do you have a seizure disorder (epilepsy)?

List Medications:

4. Do you have diabetes Adult or Juvenile?

5. Have you ever been found to be anemic (low blood count)?

6. Do you have High Blood Pressure (hypertension)?

List 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 asthma?

List 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. What are your goals for the next three months?

19. Have you had your body fat tested?

If yes, what percent is it?

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

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 East County Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of El Cajon. The purpose of East County 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 East County Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by East County 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 East County 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 East County 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/East County 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!

Your signature will be required at the time of your evaluation and you agree to the terms now!

_____________________________
Signature

____________________________
Printed Name

__________________
Date

I agree to all Terms and Conditions listed above

For More Information, Contact us at (619) 588-7300 or e-mail getfit@eastcountyadventurebootcamp.com