|
|
QUESTION
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YES
|
NO
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|
1
|
Are
you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
|
q
|
q
|
|
2
|
Do
you take any prescribed medication on a permanent or semi-permanent basis?
|
q
|
q
|
|
3
|
Do
you have a seizure disorder (epilepsy)?
|
q
|
q
|
|
4
|
Do
you have diabetes; Type I (IDDM) or Type II (NIDM)?
|
q
|
q
|
|
5
|
Have
you ever been found to be anemic (low blood count)?
|
q
|
q
|
|
6
|
Do
you have High Blood Pressure (hypertension)?
|
q
|
q
|
|
7
|
Do
you have or have you ever had Heart Disease?
|
q
|
q
|
|
8
|
Do
you have or have you ever had Lung Disease?
|
q
|
q
|
|
9
|
Do
you have or have you ever had Kidney Disease?
|
q
|
q
|
|
10
|
Do
you have or have you ever had Liver Disease?
|
q
|
q
|
|
11
|
Do
you have or have you ever had asthma?
|
q
|
q
|
|
12
|
Do
you have or have you ever had severe neck injury?
|
q
|
q
|
|
13
|
Have
you ever had been knocked out?
|
q
|
q
|
|
14
|
Have
you had a broken bone or fracture in the past 2 years?
|
q
|
q
|
|
15
|
Do
you wear glasses or contact lenses?
|
q
|
q
|
|
16
|
Have
you ever injured your back?
|
q
|
q
|
|
17
|
Do
you have back pain? If YES, circle the best answer below.
|
q
|
q
|
Almost Never Seldom Occasionally Frequently with vigorous exercise
or heavy lifting
|
|
18
|
Have
you had knee pain in the past 2 years that has disabled you for longer than a
week?
|
q
|
q
|
|
19
|
Do
you have other physical conditions, which cause pain?
|
q
|
q
|
|
20
|
Have
you had any surgical procedures?
|
q
|
q
|
|
21
|
Have
ever had your body fat tested?
|
q
|
q
|
|
22
|
Are
you training for a specific event?
|
q
|
q
|
|
If you are unsure about
the definition of any terms in this form, please call us to clarify. Do not
assume.
|
18. What are your goals for the next three months?
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PLEASE EXPLAIN ALL “YES”
ANSWERS BELOW. PLEASE REFERENCE THE QUESTION NUMBER.
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NOTICE:
It is wise to seek your
doctor’s advice BEFORE beginning any health/fitness/nutrition program!
Informed Consent, Waiver, and Release Agreement
This release is entered into between
the undersigned and A/C Adventures Inc., Puget Sound Adventure Boot Camp, its
officers, trainers, affiliates, trainers and executors in addition to the City
of Federal Way, Kent, Auburn, Federal Way School District, Kent School
District, and the county of King. The purpose of A/C Adventures Inc. is to
provide fitness instruction and coaching for various levels of
athletes/individuals.
-
The
undersigned hereby acknowledges that the following was explained to me and/or
agree to the following:
-
Acknowledges that the instructor is not a physician and is
not trained in any way to provide medical diagnosis or any other type of medical advice.
-
Acknowledges that coaching/training is another tool for
teaching athletes/individuals about themselves, but Adventure Boot Camp and A/C
Adventures Inc. does not guarantee neither good nor bad will occur, nor
guarantees the training advice given by Adventure Boot Camp and A/C Adventures
Inc. or its instructors will produce good nor bad results.
-
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.
-
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
inherent dangers of the natural elements, 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 and A/C Adventures Inc. 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
neither representatives of Puget Sound Adventure Boot Camp or A/C ADVENTURES
INC. nor anyone else has 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.
PERFORMANCE PLEDGE
In the spirit of harnessing your
best effort and providing optimum results from your Boot Camp experience, we
have established the following policies to which you will need to adhere.
Please read and initial each one.
I agree
that I will not consume alcohol during the month of Boot Camp.
I agree not
to use foul language during Boot Camp.
I agree not
to eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during
the course of Boot Camp.
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.
I will
arrive at camp ON TIME.
(Any
violation of the above statements 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 without
compensation. I understand that my "before & after" photos will
not be used for any promotional purposes unless I give written authorization.
I understand there is a no
refund policy, but I can receive a credit (for unused portion of camp) towards
a future camp if, for reasons beyond my control, I am not able to complete the
one I originally joined. Yearly
package deal sessions can only be used in the year it is purchased and is non-refundable or transferable to the following year. Camp fees cannot be used towards any other products or services
provided by A/C Adventures Inc.
______________________________
_____________________________ ____ /
___ / ____
Signature Printed
Name Date