Anaheim Hills Boot Camp REGISTRATION

If you chose option A, follow these instructions below. If you chose option B, please go back to the registration form and send it in via internet.

1. Print your information clearly or type
2. Mail to:
Anaheim Hills Adventure Boot Camp (or Anaheim Hills ABC)
8482 E. Meadowridge St.
Anaheim Hills, CA 92808
If you are paying by check, please make payable to Anaheim Hills ABC.
3. You will be notified to schedule your pre-camp evaluation (if needed for your program).

Name:______________________________________
Street:______________________________________
City:_______________________________________
State:______________________________________
Zip:_______________
Profession: _________________________________
Date of Birth ___/___/___

Home Phone (_____)____________________   Cell Phone (_____)_____________________
Fax Number (___)_______________________
E-mail (must have, you will receive email confirmations... please check often) _________________@_____________
I rate my current fitness level as a   _____ (1-10), ten being high.
***I was referred by/How did you hear about us?:
______________________________________________________________________.

Is this your first camp?    yes     no      If no, when was the last camp you attended? _________________________________________________________.
My main goal is to ____________________________________________________________________.

Emergency Contact and phone number______________________________________________________

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

*Visa and Mastercard
In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a special 3 digit code. This 3 digit code is your CVC.
American Express
On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code.

Date camp begins:_________

Circle below:
- 5 days, 3 days/evenings or 4 evenings?
- 5:30 a.m. or 6:30 p.m.?

Total price of camp (you can check prices on the registration form):$____________

If paying by check, please make payable to Anaheim Hills ABC
8482 E. Meadowridge St.
Anaheim Hills, CA 92808 Waiver must be signed prior to participation.

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

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!

This release is entered into between the undersigned and Anaheim Hills Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Anaheim Hills, the City of Yorba Linda, El Rancho Charter School, Placentia-Linda School District and the County of Orange. The purpose of Anaheim Hills Adventure 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 Jaime Hoben 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 Anaheim Hills Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Anaheim Hills Adventure 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 Anaheim Hills Adventure Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.

I agree not to use foul language during Boot Camp. 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 Camp fees cannot be used towards any other products or services provided by Anaheim Hills Adventure Boot Camp.
I will remember to set my alarm (or 2 alarms) and be at camp on time.
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, 20 ab criss-crosses, or 20 dips per occurrence - instructors choice!
I UNDERSTAND THAT I AM SIGNING UP FOR 4 WEEKS - NO EXCUSES! If you have a pre-planned trip and know you will miss a couple days of camp, you MUST let your instructor know before you sign up in order to receive up to 2 days credit towards a future camp. We cannot credit towards injuries occurring out of camp.
And lastly, I WILL NOT stop coming to camp completely. I am signing up for 4-weeks and I promise to not get lazy and not finish camp! It's only 4-weeks, I CAN DO IT!

The Undersigned agrees that this is the full agreement between the parties, that Anaheim Hills 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 agree to all of above.

____________________
Signature
____________________
Printed Name
____________________
Date

First & Last Name on the Card:
Credit Card Number:
Card Expiration Date:
CVC Code*
Your Signature: