Thank you for registering for the Extreme Fitness Boot Camps. Please submit the form below to complete the registration process.

About You
* First Name: * Last Name:
* Street Address: * City:
* Date of Birth: * Postal Code:
* Home Phone: * Work Phone:
* Mobile Phone: * Email Address:
Profession: Sex: male female
Shirt size:    
Emergency Contact Information
* Name: * Phone:
Lifestyle and Medical History
Describe your job:
How do you rate your CURRENT fitness level? (10 = very fit):
How many hours do you regularly sleep at night?
How would you describe yourself as a physical activity participant?
What are your other goals for the next three months?
Your main fitness related goal is:
Have you had your body fat tested? yes no ---------- If yes, what is it?:
 
Are you training for a specific event?: yes no ---------- If yes,What event?:
 
Are you allergic to any medication (aspirin, penicillin, etc.)? yes no ---------- If yes,please list them:
 
Do you take any prescribed medication on a permanent / semi-permanent basis? yes no ---------- If yes, what is it?:
 
Do you smoke? yes no ---------- If yes,how many cigarettes per day?
 
Do you or have you ever suffered from the following medical conditions?
High Blood Pressure: yes no Epilepsy/fainting/dizziness: yes no
Liver/kidney condition: yes no Asthma/respiratory illness: yes no
Heart condition: yes no Diabetes: yes no
Strokes: yes no Infectious skin disorders: yes no
If yes to any of the above, please specify:
Have you ever suffered from any of the following?
Arthritis: yes no Cramps: yes no
Shoulder/collar bone: yes no Wrist/hand: yes no
Lower back pain: yes no Knee/thigh: yes no
Bone fracture: yes no Muscular pain: yes no
Head/neck: yes no Arm/elbow: yes no
Upper back: yes no Hip/pelvis: yes no
Ankle/foot: yes no Chest Pains: yes no
If yes to any of the above, please specify:
Do you wear glasses or contact lenses? yes no  
Do you have any work related injuries? yes no ------------ If yes,please elaborate?
   
Do you have other physical conditions, which cause pain? yes no ------------ If yes,please elaborate?
   
Detail any surgical procedures:
Name of your GP:
Telephone of your GP:
I was referred by:
Please specify publication / website / friend or other referral:
NOTICE: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition programme!
Boot Camps Time Options:
* Please select the time for which you wish to register for: 7:00am - 8:00am Monday, Wednesday,Thursday and Saturday at 10am
  7:30pm - 8:30pm Monday, Wednesday, Thursday and Saturday at 10am
The above information is accurate and, to my best knowledge, represents my present health. I understand that this information is confidentialand provided for my safety as a client/participant in a boot camp programme or personal coaching.