Boot Camp Registration Form and Release

Thank you for registering for Vegas Valley Boot Camp. Please complete the and submit the registration form below. Once you have completed the form you will receive a confirmation receipt. Please print and bring receipt with you to your first class.

You may also pay by check at the boot camp location you are attending. Please make checks payable to Vegas Valley Fitness.

If you have already registered, please click here.

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone:
Email:
Date of Birth: / /
Gender: M   F
Emergency Contact:
Contact's Phone:
Fitness Level: (1-10, 10 being the best)
My Fitness goal is to:
 
First Boot Camp
class you will
attend:

(after the first day you can go to whichever
time and location you want)
 
Your First Day of
boot camp:

Please enter a day after Today's Date

Number of days
per week (1-4):
Comments:

Please, read each question carefully and indicate Yes or No by checking appropriate box:

Yes No Has your doctor ever said that you have a heart condition?
Yes No Has your doctor ever told you that your blood pressure was too high?
Yes No Do you experience loss of balance due to dizziness or do you ever lose consciousness?
Yes No Do you have a bone or joint problem that is aggravated by physical activity?
Yes No Do you have high cholesterol?
Yes No Are you over 65 years of age and not accustomed to vigorous exercise?
Yes No Are you pregnant?
Yes No Do you know of any other reason that would not allow you to participate in a physical fitness program?
Yes No Do you currently participate in any physical activity?
Yes No Do you have a history of heart problems, chest pain or stroke?
Yes No Do you have a family history of heart problems?
Yes No Do you have High blood pressure?
Yes No Do you have any chronic illness or condition?
Yes No Do you have difficulty with physical exercise?
Yes No Have you recently had surgery?
Yes No Are you, or have you been pregnant within the last 3 months?
Yes No Do you have a history of breathing or lung problems?
Yes No Do you have muscle or joint problems or any injuries?
Yes No Do you have diabetes or a thyroid condition?
Yes No Do you have a cigarette smoking habit? If yes, Explain.
Yes No Do you have a hernia? If yes, Explain.
Yes No Do you ever feel weak, fatigued, or sluggish?
   
If you marked yes to any of the above questions, please explain.

I agree to the following User Agreement

I agree