Survival Fitness Boot Camp
REGISTRATION
You have 2 options:

A. You can print this form and bring it with you the first day of camp.
B. Pay via secure Paypal over the internet, then fill out and submit the online form below.
You don't need a Paypal Account to use this service. (Select "Shipping Information is not required").
After "Checking Out" with Paypal, please fill out and submit the online form below.

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

john.caylor@survivalfitnessbootcamp.com
Phone: (909) 730-2367

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Enter Email:

Enter Date of Birth:
Month:
Date:
Year:

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How did you hear about us?

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On a scale of 1 to 10, I rate my current fitness level
Select One 1 - very poor 2 3 4 5 - average 6 7 8 9 10 - excellent

I was referred by (if applicable)

Is this your first camp?
Select One Yes No

My main goal is

Emergency contact phone number

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MEDICAL HISTORY INFORMATION
(If you are a returning camper, only fill in sections
that have changed)

Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
Select One Yes No
If so, list medications

List any prescribed medications you take on a permanent or semi-permanent basis?

Do you have a seizure disorder (epilepsy)?
Select One Yes No
If so, list medications

Do you have diabetes Adult or Juvenile?
Select One Yes No

Have you ever been found to be anemic (low blood count)?
Select One Yes No

Do you have High Blood Pressure (hypertension)?
Select One Yes No
If so, list medications

Do you have or have you ever had the following diseases?

Heart Disease?
Select One Yes No

Lung Disease?
Select One Yes No

Kidney Disease?
Select One Yes No

Liver Disease?
Select One Yes No

Do you have asthma?
Select One Yes No
If so, list medications

Have you ever had a severe neck injury?
Select One Yes No
Describe

Have you ever been knocked out?
Select One Yes No
Describe

Do you wear glasses or contact lenses?
Select One Yes No

Have you had a broken bone or fracture in the past 2 years?
Select One Yes No
Describe

Have you ever injured your back?
Select One Yes No
Describe

Do you have back pain?
Select One Yes No

Have you had knee pain in the past 2 years that has disabled you for longer than a week?
Select One Yes No
Describe

Do you have other physical conditions which cause pain?
Select One Yes No
Describe

Detail any surgical procedures:

What are your goals for the next three months?

Have you had your body fat tested?
Select One Yes No
If yes, what percent is it?

Are you training for a specific event?
Select One Yes No
If yes, explain:

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RELEASE
This release is entered into between the undersigned and Survival Fitness Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to Coeur d'Alene. The purpose of Survival Fitness Boot Camp 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 John Caylor 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 Survival Fitness Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by John Caylor including Survival Fitness Boot Camp 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 Survival Fitness 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 Survival Fitness Boot Camp including John Caylor 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.

Checkmark the following:

I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence.

I agree not 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 Survival Fitness Boot Camp.

I will remember to set my alarm and be at camp on time.

I understand that diet and nutrition will effect my fitness goals and performance during boot camp.

I will bring a positive attitude, and expect to have fun!

Your signature will be required at the time of your evaluation and you agree to the terms now!

I agree to all Terms and Conditions listed above