Boot Camp Registration Form
Please Complete Form.
After Submitting Information Form, Please Follow Instructions for Submitting Payment.
*
indicates required fields
*
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
*
Email:
*
Emergency Contact:
*
Relationship:
*
Phone:
*
Sex:
Male
Female
*
Date of Birth:
*
History of Heart Problems:
Yes
No
*
High Blood Pressure:
Yes
No
*
Diabetes:
Yes
No
*
High Cholesterol:
Yes
No
*
Surgery in the Last 5 Years:
Yes
No
*
Pregnancy in the Last Year:
Yes
No
*
Breathing Problems:
Yes
No
*
Smoking Habit:
Yes
No
*
Joint Problems:
Yes
No
*
Any Other Chronic Illness or Condition:
Yes
No
*
Advice from Physician NOT to Exercise:
Yes
No
Explain:
*
Camp Date:
February 2012
Camp Time:
Morning
Evening
*
Location:
Morgantown, WV
Lafayette, LA
*
ELECTRONIC SIGNATURE:
*
Date:
Please click on the Submit button to submit the form details.
Louisiana: Lafayette · Broussard · Morgan City · Carencro
West Virginia: Morgantown · Fairmont
Home
|
Services/Rates
|
Polar BodyAge
|
Testimonials
|
Nutrition
|
Photos
|
Contact Us
©2006-2011
JUSTINSHAPE
407-928-3700
email:
jshroyer@justinshape.com
Site Map
