New Jersey Adventure Boot Camp Class
REGISTRATION

Here’s how you register:

1. PRINT THIS REGISTRATION FORM by clicking here. Please fill out the form completely and print your information clearly.

2. Choose your method of payment:

NOTE: We cannot guarantee your space will be reserved if you do not supply us with your payment.

A. CHECK – please make your check payable to: NJ Adventure Boot Camp and mail with your completed registration form to: NJ Adventure Boot Camp, PO Box 609,Peapack, NJ 07977

B. CREDIT CARD – For “SECURE” online payment using VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS or PayPal, select $399 (5 days/week) or $239 (3 days/week)

C. CLICK PayPal BUY NOW button below to proceed with your payment, then FAX your completed registration form to 908-234-9112 or mail to: NJ Adventure Boot Camp, PO Box 609, Peapack, NJ 07977

Women Only Boot Camp
$239 (3 days/week) $399 (5 days/week)
Men's Fall Camp
$239 (3 days/week) $399 (5 days/week)

3. You will be notified to schedule your pre-camp evaluation.

Note: Spaces fill quickly! Register early to guarantee your spot in the upcoming camp!
NOTE: We cannot guarantee your space will be reserved if you do not supply us with your payment.


 Name:______________________________________

Street:______________________________________

City:_______________________________________

State:______________________________________

Zip:_______________

Profession: _________________________________

Date of Birth ___/___/___

Home Phone (_____)____________________   Work Phone (_____)_____________________

Fax Number (___)_______________________

E-mail _________________@_____________

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

I was referred by ______________________________________________________________________.

My main goal is to ____________________________________________________________________.

Emergency Contact and phone number______________________________________________________

I will be paying by: (circle one) Check    MasterCard    Visa    American Express    Discover

$239 (3days/week) $399 (5 days/week)

What is the name & time of the program you are joining?

__________________________________________________ Price of program $ _____

What is the location of the camp you are joining?

__________________________________________________

If paying by check, please make payable to New Jersey Adventure Boot Camp.
PO Box 609, Peapack, NJ 07977.  Waiver must be signed prior to participation.


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)? Yes No

4. Do you have diabetes Adult or Juvenile? Yes No

List Medications:
5. Have you ever been found to be anemic (low blood count)? Yes No

6. Do you have High Blood Pressure (hypertension)? Yes No
List Medications:

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
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?
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?
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 New Jersey/NJ Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to Harry Dunham Park, Bernard's Township, Gill St. Bernard's School, Gladstone, Pleasant Valley Park, Liberty Corner Church, Duke Island Park, Bridgewater Township, Loantaka Brook Reservation, Morristown, St. Luke Parish, Long Valley and the College of St. Elizabeth. The purpose of NJ Adventure Boot Camp Corp. 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 Valerie Pawlowski 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 NJ Adventure Boot Camp Corp. does not guarantee neither good nor bad will occur nor guarantees the training advice given by NJ Adventure Boot Camp Corp. 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 NJ 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 NJ 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. I

____________________
Signature

____________________
Printed Name

____________________
Date

njbootcamp@patmedia.net

$399 (5 days/week) $239 (3days/week)