Boot Camp Chicks - Registration

Camp starts every 4-weeks at

Desert Trails Elementary School

4315 East Cashman Dr.

Phoenix, AZ 85050

5:30 - 6:30 AM.

Hurry and register, CAMP FILLS FAST!
What are you waiting for?
Empower yourself!

Email:	kim@bootcampchicks.com
Phone:	(602) 448-8819

Jump Start Your Fitness Program With Other Boot Camp Chicks!

Boot Camp Chicks Registration

Register Online

1. Fill-out the form below
2. Select "Submit, I am ready to get fit!"

3. Pay online using our secure system.

4. Returning campers click HERE.

* We cannot guarantee your space will be reserved if you do

not supply us with payment information on this form if sending online.

* Denotes a required field

Your Information
Name	*
Mailing Address	*	(Must match credit card)
City	*
State	*
Zip	*
Physical Address (if different from above)
Profession
Date of Birth	*	(mm/dd/yyyy)
Phone Number - Home	*
Phone Number - Work
Phone Number - Cell
Email:	*	(So you can get updates from me!)

I rate my current fitness level as?	*	(1-10, 10 being high)
How did you hear about us?	*	If "Friend/Co-Worker", please list name:
My main goal is:	*
This is my first camp?	*	Yes No If "No", when was the last camp you attended:

Emergency Contact
Contact Name	*
Phone Number	*

Boot Camp Class
Which program are you signing up for?	*	Boot Camp Classes: $255 - 5 days a week for 4 weeks $210 - 4 days a week for 4 weeks $170 - 3 days a week for 4 weeks Note - There will be greater results attending the full 5 days of camp
Which time are you signing up for?	*
PLEASE verify you have put the correct program and price before sending.
Please select days and price:	*

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.)?	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)?
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.	Check if 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? Please describe.
10.	Have you ever been knocked out? Please describe.
11.	Do you wear glasses or contact lenses?
12.	Have you had a broken bone or fracture in the past two years? Please describe.
13.	Have you ever injured your back? Please 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? Please describe.
16.	Do you have other physical conditions which cause pain? Please describe.
17.	Detail any surgical procedures:
18.	Have you had your body fat tested?	If yes, what percent? %
19.	Are you training for a specific event? If yes, please explain.

Release
*NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!* This release is entered into between the undersigned and Boot Camp Chicks, its officers, subsidiaries, affiliates, and executors in addition to the Paradise Valley Unified School District. The purpose of Boot Camp Chicks 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 Kim Robinson 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 Boot Camp Chicks does not guarantee neither good nor bad will occur nor guarantees the training advice given by Boot Camp Chicks 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 Boot Camp Chicks, Kim Robinson or Paradise Valley Unified School District 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 Boot Camp Chicks 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.

Customer client agrees to confitentiality with respect to Boot Camp Chicks and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of Boot Camp Chicks. The undersigned agrees to a non-compete within a 50 mile radius of "Desert Ridge" Phoenix for a period of 5 years from date of participation.

Terms & Conditions
Please checkmark ALL of the following boxes:
	I agree not to use foul language during Boot Camp. 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 and Camp fees cannot be used towards any other products or services provided by Boot Camp Chicks.
	*I agree 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 20 push-ups per occurrence.**
	I will remember to set my alarm (or 2 alarms) and be at camp on time.
	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, 20 ab crunches, or 20 dips per occurrence - instructors choice!
	I UNDERSTAND THAT I AM SIGNING UP FOR CAMP - NO EXCUSES! If you have a pre-planned trip and know you will miss a couple days of camp, you MUST let your instructor know before you sign up in order to receive credit towards a future camp. We cannot credit towards injuries occurring out of camp.
	And lastly, I WILL NOT stop coming to camp completely. I am signing up for 4-weeks and I promise to not get lazy and not finish camp! It's only 4-weeks, I CAN DO IT! (please check this box for FREE session camp too)
By clicking on the "Submit, I am ready to get fit!" button below, you agree to all of the terms above and acknowledge that you filled out this form with complete honesty. I agree to all Terms and Conditions listed above To submit your registration, you must enter access code displayed in the image below. Access code: Enter Access Code: