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Registration and payment information
New Campers
Please fill out ALL of the information below. Make sure to sign and date the PAR-Q, check the box showing you have
read and accept the waiver, and submit your information.
Returning Campers
Please fill out ALL of the information in the new and returning campers section. When completed, scroll to the bottom of
this page, check the box showing you have read and accept the waiver, and submit your information.
Methods of Payment
Credit Card
You may pay with credit card by filling in your credit card information below.
Cash or Check
You may also pay by cash or check. Bring payment with you on the first day of camp. Make all checks payable to
Adventure Boot Camp.
If you have any further questions please feel free to e-mail us santarosabootcamp@gmail.com or call 707-287-5543.
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New and Returning Campers
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* Denotes a required field
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Contact Information
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* Last Name:
* First Name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Work Phone:
Cell Phone:
* E-mail address:
* Date of Birth:
* Profession:
* How did you hear
about us?
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(MM/DD/YYYY)
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If referred, by who?
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Emergency Contact
*Emergency Contact Name:
*Emergency Contact Phone:
Class Registration
*Session I'm signing up for:
*Days I'm signing up for:
Time and Location:
*Payment Plan:
*T-Shirt Size:
*Payment Type:
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* 3 month Unlimited Plan: a 3 month minimum contract billing your credit card $167 per month. Drafted monthly after
that until a 30 day written cancellation has been received.
**12 Month Unlimited Plan: a 12 month minimum contract billing your credit card $135 per month. Drafted monthly
after that until a 30 day written cancellation has been received.
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Credit Card Information
For security reasons, your credit card information is not stored or saved within our system. Your credit card information
is required at this time to process your registration. PLEASE verify all credit card numbers are entered before sending.
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Name on Credit Card (exactly as it appears):
Credit Card:
Credit Card Number (no spaces):
Expiration Date:
CVC Code*:
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/
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*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.
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____________________________________________________________________________________________________
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NEW CAMPERS ONLY
*Returning Campers may skip to the bottom and submit registration.
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YES NO
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Physical Activity Readiness Questionnaire (PAR-Q)
1. Has a doctor ever said you have a heart condition and recommended
only medically supervised physical activity?
2. Do you ever experience any chest pain as a result of physical activity?
3. Do you ever get light headed or dizzy during normal physical activity?
4. Do you take any medication for blood pressure or a heart condition?
5. Do you currently or, have you in the past had any bone, joint, or
physical problem(s)?
6. Have you ever had any surgery that might inhibit physical activity?
7. Do you have asthma?
8. Do you wear glasses or contacts?
9. Do you have any form of diabetes?
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*If you answered yes to any of the above questions, talk with your doctor BEFORE you become more physically
active. Tell your doctor your intent to exercise and to which questions you answered yes.
If you honestly answered no to all questions you can be reasonably positive that you can safely increase your
level of physical activity gradually.
If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.
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By signing your name below it notes that this information is true and accurate.
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Signed:
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Date:
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(MM/DD/YYYY)
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(type your name here)
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____________________________________________________________________________________________________
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Your Height:
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Your weight:
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What are your short-term
fitness goals (1-3 months)?
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What are your short-term
fitness goals (6-12 months)?
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* If weight loss is one of your goals, understand that nutrition plays a large roll in it's success. You
will be encouraged and highly recommended to do a daily food log and turn it in to your instructor
weekly.
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Are you currently exercising?
If yes, what are you doing?
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Have you had any broken bones in the past 2 years?
If yes, please explain
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Have you ever injured your back?
If yes, please explain
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Do you have any knee, or have you had any knee pain in the past?
If yes, please explain
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Have you ever had your body fat tested?
If yes, what is your most recent BF percentage?
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%
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Informed Consent, Waiver and Release Agreement
I hereby acknowledge, understand, and agree to the following:
- The purpose of the Santa Rosa Adventure Boot Camp Program offered by Jeffrey Sears and Jaron Eliopoulos (the "Program") is to provide
fitness instruction and coaching to athletes and individuals at various levels of performance and ability. Such fitness instruction/coaching is
one of many tools for teaching athletes and individuals about themselves, their bodies and athletic abilities. THERE IS NO GUARANTEE
THAT PARTICIPATION IN THE PROGRAM WILL PRODUCE ANY SPECIFIC RESULTS. Neither Santa Rosa Adventure Boot Camp, Jaron
Eliopoulos, nor Jeffrey Sears make any such promise or guarantee.
- I have been instructed that if I feel tired, feel pain or feel out of the ordinary in any way, at any point in the Program, or in any way related to my
training, or otherwise, that I should contact a physician at once. Santa Rosa Adventure Boot Camp has recommended that I consult a
physician prior to starting any health/fitness/nutrition program.
- Jeffrey Sears, Jaron Eliopoulos, and any other Program instructors, are NOT physicians and are not trained in any way to provide medical
diagnosis or any other type of medical advice.
- Boot camps, aerobic classes, running, weight training, obstacle courses, and any other related sports are extreme tests of one's mental and
physical limits and carry with them potential for serious injury and death as well as damage or loss of property. I hereby assume any and all
risks of participating in these types of events and activities, including my participation in the Program, and represent that I am fit and that I am
under the regular care of a medical physician that I can contact regarding any medical problems that might develop.
- I expressly agree to waive, release, discharge, indemnify, hold harmless and defend, Santa Rosa Adventure Boot Camp, Jeffrey Sears, Jaron
Eliopoulos, Sonoma County, the City of Santa Rosa, and their/its respective instructors, officers, officials, agents, employees, volunteers and
affiliates, from any liability, claims, demands, losses, damages for any injury of any kind whatsoever, including but not limited to death,
disability, personal injury, or property damage arising from or in any way related to my participation in the Program.
- This is the full agreement between Santa Rosa Adventure Boot Camp and me. Neither representatives of Santa Rosa Adventure Boot Camp,
Jeffrey Sears, Jaron Eliopoulos, nor anyone else has verbally contradicted any of the terms of this agreement. I have entered into this
agreement free and voluntarily without force or coercion, and without relying on any representation or warranty outside those expressly set
forth in this agreement.
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Note: ALL new campers will be required to fill out a supplemental health form at their pre-camp assessment.
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By checking this box, you are agreeing to all terms and conditions above and that all information is current and true and was willingly
provided by yourself and no on else.
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Promo Code:
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(If you have a promo code, please enter it here)
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If you have any additional comments
or notes for us, please list them here:
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Please click submit to complete your registration
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