Don’t Wait Another Minute
To Jump Start Your Fitness & Weight Loss!
At The Adventure Boot Camp we know how difficult finding an effective workout regime can be. If you are serious about getting results and reclaiming your attractive, healthy, and energetic body and stop “spinning your wheels” once and for all, please don’t wait another minute to contact us.
We are happy to provide you a no-obligation, no-charge consultation to discuss your goals and how The Adventure Boot Camp can work for you.
Yes! I Want My Body Back!
You have two options:
1. You can print this form by using the print option in your web browser and send it in by fax,mail or email.
2.Pay securely online using PayPal.
If you choose option one, follow these instructions.
Print This Boot Camp Registration Form
1. Print your information clearly or type
2. FAX to: (204) 895-7108 or mail to:
Winnipeg Adventure BootCamp
202-2075 Portage Avenue,Winnipeg,Manitoba,R3J 0L1
If you are paying by Check or Money order, please make payable to Winnipeg Adventure BootCamp.
All pricing is subject to 5% GST.
3. You will be notified to schedule your pre-camp evaluation.
YES, I’m ready for the Adventure Boot Camp. Sign me up!
You can pay over the internet securely using
 |
Click on either Boot Camp option below to send your payment over the internet.
Option #1. -3 times per week for $180.00 + 5% GST
Option #2. -5 day per week plan for $299.00 + 5% GST
Name:______________________________
Street:_____________________________
City:_______________________________
Province:___________________________
Postal Code:_______________
Profession:__________________________
Date of Birth___/____/____Emergency Contact and phone number_______________________
I’m signing up for the camp beginning on this date
____/____/____/
The start time for this camp is ___5:45 am___7:00 am
___6:00 pm
This is my first camp ____The last camp I attended was _________
Home Phone (____)________________
Work Phone (____)________________
Fax Number (____)________________
Email___________@_______________
I rate my current fitness level as a _____(1-10), ten
being high.
I was referred by_________________
My main goal is to___________________________
__________________________________________
I will be paying by: (circle one) Check Paypal Cash Credit Card
Credits cards will be charged $299
You can also attend 3x/week for just $180.00
We prefer if you attend M,W,F of each week. Most ladies decide to add days after enrolling in the 3-day program.
Option #1 – 3 times per week for $180.00 + 5% GST____
Option #2 – 5 day per week plan for $299 + 5% GST____
If paying by check or money order, please make payable to Winnipeg Adventure BootCamp
202-2075 Portage Avenue,Wpg,Mb,R3J 0L1
Confirmations and detailed instructions will be emailed prior to the start of Camp. Wavier must be signed prior to participation.
MEDICAL HISTORY
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
5. Have you ever been found to be anemic (low blood count)? Yes No
6. Do you have High Blood Pressure (hypertension)? Yes No
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
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 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 Winnipeg Adventure BootCamp/Jason P Brown.
Winnipeg Adventure BootCamp, it’s officers, affiliates,
and executors in addition to the City of Winnipeg,Assiniboine Park and Winnipeg Parks and Recreation. The purpose of Winnipeg Adventure BootCamp 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 Jason P Brown 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 Winnipeg Adventure BootCamp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Winnipeg Adventure BootCamp 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, 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 potential for damage or loss of property, serious injury and death. That the undersigned assumes the risks of participanting in these types of events/activites, 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. Winnipeg Adventure BootCamp 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 Jason P Brown nor anyone else has not verbally contradicted any of the terms of this release and the undersigned has entered into this agreement free anmd voluntarily withouy force or coercion.
Intitial the following:
___I agree that I will not consume alcohol
during the month of Boot Camp. Any violation
will result in twenty push-ups
___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 Donuts,
Cup Cake, Cake or Twinkie 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 ther 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 originally joined. Camp fees cannot
be used towards any other products or services
provided by Winnipeg Adventure BootCamp
___I will remember to set my alarm and be at
camp ON TIME.
_______________________
Signature
_______________________
Printed Name
_______________________
Date