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Date & Program
Select your location:
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Lantana 5:30 AM M/W/F
Lantana 8:00 AM M/W/F
Select your camp date:
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January 23
February 27
April 10
May 15
June 19
July 24
August 28
October 2
November 6
December 11
Select your program:
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3 Day ($179)
VIP 3 Day ($99) *Your rate after 3 camps
You may attend any camp time on a daily basis regarless of which time you select!
Contact Information
First Name
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Last Name
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Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Email Address (primary):
(will not be shared - only used to communicate with you about camp, food logs, etc.)
*
Email Address (secondary - not required):
Phone Number:
(for postponed/rescheduled class updates)
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Date of Birth (MM/DD/YY):
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Age:
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Occupation:
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Emergency Contact (Name):
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Emergency Contact (Phone):
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Body Weight & Goals
Height:
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Current Weight:
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Goal Weight:
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What are your health and fitness goals?
Check all that apply:
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Achieve balance in life
Control blood pressure
Control cholesterol
Exercise regularly
Feel better overall
Improve cardiovascular fitness
Improve flexibility
Improve muscle tone
Improve nutritional habits
Improve productivity
Increase muscle mass
Increase Strength and endurance
Injury rehab
Reduce body fat
Reduce stress
Reduce back pain
Stop smoking
Other
Other
Physical Activity & Nutrition
Activity Level
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Sedentary
Moderate (<3times/week)
Active(>3 times/week)
How often do you eat fast food?
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5 days/wk
3 days/wk
1 day/wk
1 day/mth
none/rarely
Do you have a good understanding of what nutrients and what proportions should be planned into each meal?
*
Medical Information
Regular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program. To help us determine if you should consult with your doctor before starting an exercise program at Body Bionics, please read carefully and honestly answer the following questions. All information will be kept confidential.
Please complete the following:
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Yes
No
N/A
Has a physician ever told you or are you aware that you have a heart condition?
Yes
No
N/A
Have you ever experienced a stroke?
Yes
No
N/A
Do you or have you smoked within the last six months?
Yes
No
N/A
Do you have high blood pressure?
Yes
No
N/A
Do you have high cholesterol?
Yes
No
N/A
Has anyone in your immediate family (parents, brothers, sisters) had a heart attack, stroke or cardiovascular disease before the age of 65 (if you are a woman) or 55 (if you are a man)?
Yes
No
N/A
Do you have diabetes?
Yes
No
N/A
Do you have a joint or bone problem that may be made worse by a change in your physical activity?
Yes
No
N/A
Are you a female over 54 years of age or a male over 44 years of age?
Yes
No
N/A
Do you consider yourself to have an inactive lifestyle?
Yes
No
N/A
Are you overweight?
Yes
No
N/A
Do you have any of the following: asthma, epilepsy, emphysema or arthritis? If yes, list below.
Yes
No
N/A
Do you feel pain in your chest when you engage in physical activity?
Yes
No
N/A
Do you feel pain in your chest when you are NOT engaged in physical activity?
Yes
No
N/A
Have you ever had unusual shortness of breath at rest or with mild exertion?
Yes
No
N/A
Do you ever suffer from dizziness or fainting spells?
Yes
No
N/A
Are you currently taking medications? If yes, list below.
Yes
No
N/A
Women: Are you pregnant or have you been pregnant within the last three months?
Yes
No
N/A
NOTES:
If you answered YES to any of the questions above, please provide as much detail as possible in the field below for each YES answer. It is not uncommon for Medical Releases to be requested. So please help us properly determine if one might be necessary. IF YOU ARE REGISTERING THE DAY BEFORE CAMP BEGINS, PLEASE CONTACT US VIA PHONE AFTER YOU SUBMIT ONLINE. We must review your medical history responses prior to any admission to the boot camp.
I have answered the above accurately and completely. I understand that my medical history is an important factor in the development of my fitness program and that certain medical/physical conditions which are known to me, but which I do not disclose to Body Bionics may result in serious injury to me. If any of the above conditions change, I will immediately inform Body Bionics. I, knowingly and willingly, assume all risk of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the above questionnaire.
Waiver of Liability & Informed Consent
I have enrolled in a program of strenuous physical activity including but not limited to cardiovascular and resistance training by Body Bionics. I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit my participation in this exercise program. In consideration of my participation in the exercise program, I for myself, my heirs and assigns, hereby release Body Bionics and its partners* from any claims, demands and causes of action arising from my participation in the exercise program by Body Bionics. I fully understand that I may injure myself as a result of my participation in the exercise program and I hereby release Body Bionics and its partners* from any liability now or in the future including but not limited to heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat related injuries/illnesses, knee/foot/low back injuries and any other illness, soreness or injury however caused, occurring during or after my participation in the exercise program.
In addition, I understand that Body Bionics frequently captures images of its boot camp sessions and participants via photo and/or video. I am aware that these images may contain photos and/or videos of me. I further understand that Body Bionics owns these images and the right to use them for marketing purposes including but not limited to website postings and printed materials.
*Partners include but are not limited to businesses and or organizations that provide access to and use of their facilities where Body Bionics hosts exercise programs.
By registering and submitting payment, I acknowledge that I have read, understand and agree with the above statements and conditions and agree to abide by them.
Payment Information
Name on Card
*
Billing Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
CSC Code
*
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Expiration Date (mm/yy)
*