YOUTH BOOT CAMP REGISTRATION

You have 3 payment options: Pay by Cash, Check, Credit Card.
Note: We accept all major credit cards. All forms of payment may be taken at our office.

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:
Naples Youth Fitness Boot Camp
Mailing Address:                                                            Office Address:
5644 Tavilla Cir #102                                       5644 Tavilla Circle #102
Naples, FL 34110                                                          Naples, FL 34110
trainoutdoor@gmail.com
Phone: (239) 431-6526 Office
            (239) 206-1920 direct

Additional instructions:

****PLEASE ENSURE YOU CHECK THE CALENDAR TO ENSURE CLASS IS NOT FULL****

If you chose the option to pay by Check: please fill out the form below and click Submit . . . I am ready to get fit!" you will be redirected to the secure payment page then select the option to print and call. Print that page out and mail your payment to the above address.

If you choose option to pay by Credit Card, please fill out the form below and click Submit . . . I am ready to get fit!" you will be redirected to the secure payment page.

FireFox and Safari Users please note that our web form does not transmit through our server. Please fill form out, print out form and bring to your pre-camp evaluation . Then click submit to be taken to the payment page.

You will be notified to schedule your pre-camp evaluation (if needed for your program).
Name
Address
City
State
ZIP
Profession
Country
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:
Indicate your T-shirt size.
What is the Event Name (from the Calendar) & Select amount of days you are attending?

Form of payment:
If paying by check, please make check out to: Naples Youth Fitness Boot Camp Mailing Address: 5644 Tavilla Cir #102 Naples, FL 34119 trainoutdoor@gmail.com Phone: (239) 431-6526 office or (239) 206-1920 Fax: (239) 206-1837 MEDICAL HISTORY (If you are a returning camper, only complete the sections that have changed.)
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes Adult or Juvenile?		List Medications:
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? Yes No
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! PARENT AND YOUTH RELEASE This release is entered into between the undersigned and Naples Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Naples. The purpose of Naples Fitness Boot Camp and Naples Youth Fitness 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 trainers are not physicians and are 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 Naples Fitness Boot Camp including Naples Youth Fitness Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Naples Fitness Boot Camp including Naples Youth Fitness 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, 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 Naples Fitness 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 Naples Fitness Boot Camp including Naples Youth Fitness 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 allow my youth to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence and possible dismissal from boot camp. I agree not to allow my youth not to 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 ensure that my youth will 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 agree to ensure that my youth will recieves enough sleep, water and healthy nutritional meals every day. Any violation will result in parent doing twenty push-ups per occurrence. I understand and agree that photos or video may be taken during the course of my youth involvement in Naples Youth Fitness 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 agree to the following refund policy: If for any reason you have to cancel prior to the first day of camp you will receive a full refund less $25 processing fee. Important: After the Monday start day there are absolutely no refunds, regardless of how many days your youth participated. This is non-negotiable. I will remember to get my youth to camp on time I understand that diet and nutrition will effect my fitness goals and performance during boot camp. I will help my youth bring a positive attitude, and expect to have fun! I also will have a positive attitude! By submitting this registration form you agree to the terms list above and release all liability of Naples Fitness Boot Camp to train your youth in the safest way possible now! ____________________ Signature ____________________ Printed Name ____________________ Date
I agree to all Terms and Conditions listed above