DEBI’S Personal Training LLC BACKYARD BOOT CAMP REGISTRATION
Option # 1 - Original Backyard Boot camp 3 times per week for 4 weeks Oor 2 times per week for 6 weeks $199	Option #2 - Original Backyard Boot Camp 5 day per week plan for 4 weeks $299	Option #3 - Original Backyard Boot camp 2 day per wk plan for 4 weeks $140	Option #4 - Corporate or School 1 day per wk 1 hours each only 6 weeks $125	Option #5 - Sat. Only Obstacle Course 4wks ~ 1 day/wk Up to 1 1/2 hours each only $129 (past campers get $30 off Obstacle Course Camp)

Please Print Clearly.      Name:______________________________________

Street:______________________________________

City:_______________________________________                State:____________    ZIP CODE__________________            


Profession: _________________________________   Employment: _______________________________________

Date of Birth ____/____/____        (would your employment be interested in “Corporate Wellness” Programs?___________)

Emergency Contact Name and phone number______________________________________________________

 

I'm signing up for the camp beginning on this date______/_______/______. Location _____________________

The start time for my camp is ___ 5:30 AM  >>>___ 9:30 AM ___ 6:00 AM     ___ Other ___ 6:30 PM         ___ 6:00 PM

This is my first camp ___ The last camp I attended was ____ _________________________

Home Phone (_____)____________________   Work Phone (_____)________________________

CELL Phone (for very important use only, unless specified)  (_____)_____ ________________(    ) Check if preferred ph. #

E-mail _________________@_____________

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      Pay Pal          Cash                 Date paid____/____/____

(NOTE:  there will be a discount for “re-enlisting” in future consecutive camps)
Check your Option # Choice Below: 

___Option #1 - 3 times per week for 4 weeks or 2 times per week 6 weeks only $199
___Option #2 - 5 day per week plan only $299
___Option #3 -- 2 day per week, 4 Week Program for 1 hour each only $140
___Option #4 - 1 day per week, 6 Week Program, (“corporate or school”) for 1 hour each only $125
___Option #5 - 1 day per week, 4 Week Obstacle Course Program Saturdays/Summer only - 1 1/2 hours each only $129

If paying by check, please make payable to Debi’s Personal Training, LLC.

19361 Whitehead Rd. Lagrange, OH 44050
Confirmations and detailed instructions will be made prior to the start of Camp.  Waiver must be signed prior to participation.

DEBI’S Personal Training LLC BACKYARD BOOT CAMP REGISTRATION Page 2

  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 a specific event? If yes, explain:

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

RELEASE

This release is entered into between the undersigned and Debi’s Personal Training LLC, Debi Balmert, Backyard Boot Camp, its officers, affiliates, and executors in addition to the City of Grafton, Twp of Lagrange, Lorain County Metro Parks, Cleveland Metro Parks, Westlake Parks and Recreation, City of North Ridgeville, Willow Park, City of Avon Lake,  City of Strongsville, City of Middleburg Hts, or any other location owners that are used for this program.  The purpose of Debi’s Personal Training LLC and Debi Balmert Backyard Boot Camp and the instructors is to provide fitness instruction and coaching for various levels of athletes/individuals.

 

 DEBI’S Personal Training LLC BACKYARD BOOT CAMP REGISTRATION Page 3

 The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:

1. Acknowledges that Debi Balmert, or any instructors are not a physician 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 Debi’s Personal Training LLC, Debi Balmert, Backyard Boot Camp, any instructors, does not guarantee neither good nor bad will occur nor guarantees the training advice given by Debi’s Personal Training LLC, Debi Balmert, Backyard Boot Camp, any instructors 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, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop.
5. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Debi’s Personal Training LLC, Debi Balmert, Backyard Boot Camp, or instructors for the undersigned participating in said sporting events and/or training for said sporting events.
6. The undersigned participant hereby agrees not to directly or indirectly compete with the business of Debi's Personal Training LLC and it's successors and assigns during the period of participation and for a period of 1 year following end of participation.  The term "not compete" as used herein shall mean that the undersigned shall not own, manage, operate, consult or to be employed in a business substantially similar to, or competitive with, the present business of Debi's Personal Training LLC, specifically the "Backyard Boot Camp" program.  The undersigned also acknowledges that Debi's Personal Training LLC shall or may in reliance of this agreement provide the undersigned access to trade secrets, customers and other confidential data and good will.  The undersigned agrees to retain said information as confidential and not to use said information on his or her own behalf or disclose same to any third party.  The non-compete agreement shall extend only for a radius of 50 miles from the present location of Debi's Personal Training LLC and shall be in full force and effect for 1 year, commencing on the date of participation.  This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.

The Undersigned agrees that this is the full agreement between the parties, that Debi Balmert, Debi’s Personal Training LLC 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.

 

Initial the following:

___ I agree that I will not consume alcohol during the month of Boot Camp. I understand that this will not help me achieve my goal.
___ I agree not to use foul language during Boot Camp.
___ I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp.  I understand that these items will not help me achieve my goal.
___ 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.  I understand that I will get the best results by attending at least 3 sessions per week.
___ 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 cannot be used towards any other products or services provided by Debi’s Personal Training LLC, Debi Balmert, Backyard Boot Camp.
 (The next one is IMPORTANT . . . to provide you with a more restful first pre-camp night’s sleep)

___I will remember to set 2 alarm clocks and be at camp ON TIME. I understand that it is important to participate in the "warm-up" exercises at the beginning of camp to prevent injury.

 

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Signature                                                           Date                                                  

 __________________________________________
Printed Name