Your Full Name
Your Email

Which boot camp time slot will you attend? Choose one.

 BAY VIEW at 6:00am BAY VIEW at 6:45am BAY VIEW at 6:00pm THIRD WARD 6:00am THIRD WARD 6:45am

What prompted you to join this program and what do you specifically hope to accomplish during this session?

How did you hear about us? Did someone refer you? If so, what is their name?

Please list previous athletic or fitness experience

Personal Information

Street Address
City
State
Zip
Phone (home)
Phone (work)

Emergency Contact

Name
Phone

Medical Information

Date of Birth
Height
Weight

Primary Provider

Name
Phone
Email

Additional Healthcare Provider (optional)

Name
Phone
Email
Type of provider

Please list any injuries, chronic illnesses (diabetes, COPD, asthma, etc), chronic aches and pains, previous surgeries, or any other physical condition or ailment that may manifest itself during training or affect your training. Please describe ALL relevant conditions in full detail:

Are you currently taking any medications? If so, please list each one and your current corresponding dosages.

Additional Comments

Please review the disclaimer and waiver (shown below) and initial.

Initial to accept the disclaimer
Initial to accept the waiver

Disclaimer

During your exercise program, every effort will be made to assure your safety. However, as with any exercise program, there are risks, including increased heart stress and the chance of musculoskeletal injuries. In volunteering for this program, you assume responsibility for these risks and waive any possibility for personal damage. You also agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude an exercise program. If you do have any medical issues that may be of concern, you further agree that a physician has cleared you to participate in a training and nutrition program.

A physician’s examination is recommended for (1) all participants with any exercise restrictions and (2) all men >44 years old and all women >54 years old. Coaching participants in either or both of these categories who do NOT have prior physician examination MUST acknowledge they have been informed of its importance. By signing below, you accept full responsibility for your own health and wellbeing and you acknowledge an understanding that the leaders of this program assume no responsibility.

GGR Fitness Media Release Waiver

I am aware that GGR Fitness may record workouts/ boot camps for later use on television segments, websites, promotional materials, fitness info products, or in any other way they deem fit.

By signing this document I hereby authorize GGR Fitness to use my name and likeness, voice, verbal statements, digital pictures, and video and audio recordings for any of the aforementioned purposes.

We will not use a direct photo of you without expressed permission.