Online Registration Form

* Please fill in all required fields

* Name:
* Street Address:
* City:
* State:
* Zip:
Profession:
* Date of Birth:	(xx/xx/xxxx)
* Home Phone Number:
Cell Phone Number:
Work Phone Number:
Fax Number:
* Email Address:
* Current Fitness Level (1-10):	(* ten being the highest)
I was referred by:
* My main goal is to:
*Emergency Contact:
Emergency Contact's Phone No.:
* Program Name:
* Program Time:
Program Fee:

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MEDICAL HISTORY
(If you are a returning camper, only complete the sections that have changed.)

1.	Are you allergic to any medication (aspirin, penicillan, sulfa, etc.)? If yes, please list medications below:
2.	Do you take any prescribed medication on a permanent or semi-permanent basis? If yes, please list medications below:
3.	Do you have a seizure disorder (epilepsy)?   YES    NO
4.	Do you have diabetes (Adult or Juvenile)?   YES   NO
	If yes, please list medications below:
5.	Have you ever been found to be anemic (low blood count)?    YES   NO
6.	Do you have High Blood Pressure (hypertension)?    YES   NO
	If yes, please list medications below:
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
8.	Do you have asthma?   YES   NO
	If yes, please list medications below:
9.	Have you ever had a severe neck injury?  YES   NO
	If yes, please describe below:
10.	Have you ever been knocked out?  YES   NO
	If yes, please describe below:
11.	Do you wear glasses or contact lenses?  YES   NO
12.	Have you had a broken bone or fracture in the past 2 years?  YES   NO
	If yes, please describe below:
13.	Have you ever injured your back?  YES   NO
	If yes, please describe below:
14.	Do you have back pain?
	Never  Seldom  Occasionally  Frequently 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?  YES   NO
	If yes, please describe below:
16.	Do you have other physical conditions which cause pain?  YES   NO
	If yes, please describe below:
17.	Detail any surgical procedures below:
18.	What are your goals for the next three months?
19.	Have you ever had your body fat tested?  YES   NO
	If yes, what percent is it?
20.	Are you training for a specific event?  YES   NO
	If yes, please explain below:
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 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 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 Debra Berney or Wellness On Wheels, LLC.   I will remember to set my alarm and be at camp on time.
* Click here to read our Release Agreement    I AGREE   I DISAGREE

NOTICE: It is wise to seek your doctor's advice before beginning any health/
fitness/nutrition program!

* Waiver must be signed prior to participation.