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Boot Camp Registration

Hart Boot Camp Class
REGISTRATION

Fill out this form completely
1. Submit the form via the internet and mail payment.
2. Print this form and send it in with payment by mail.

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

If paying by check, please make check out to:
Hart Boot Camp of Missoula
1835 35th St.
Missoula, MT 59801
Cindy@HartBootCamp.com
Phone: (406) 544-0395

You will be notified to schedule your pre-camp evaluation (if needed for your program).

Full Name

Street Address

City

State

ZIP

Profession

Country

Date of Birth

(mm/dd/yyyy)

Phone Number

Work Number

Email Address

I rate my current fitness level as a (1-10), ten being high.

I was referred by:

Please specify publication / website / friend or other referral:

This is my first camp:

Yes | No

If you answered "no", when was the last camp you attended:

My Main goal is:

Name of Emergency Contact & Phone Number

What is the date and time of the program which you are joining? Please specify morning/evening and Missoula/Bitterroot!

Form of payment:

$199 (5 days/week) | *$150 (3days/week) *This option is for those who have other commitments in the early a.m. Since it is only a 4-week class, we do prefer you to attend the full 5-day a week program for best results and overall work-out! You can do it!! )

If Signing up for the Consecutive Month Discount Program Please check the Authorization at the Bottom of the Page
Note: If paying by check, please print this online form and mail or fax it in with payment. *Please note - we cannot guarantee your reserved spot until payment is received.
The above address is the same as the billing. Otherwise, please enter billing address below. Leave blank if the same.
Address
City
State
ZIP
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.

Credit Card Number:		Exp. Date:	/
Name on Credit Card:		*CVC Code:**	(security code)

*Only Visa and MasterCard Accepted
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.

MEDICAL HISTORY (If you are a returning camper, only complete the sections that have changed.)

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

List Medications:

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

List Medications:

3. Do you have a seizure disorder (epilepsy)?

List Medications:

4. Do you have diabetes Adult or Juvenile?

5. Have you ever been found to be anemic (low blood count)?

6. Do you have High Blood Pressure (hypertension)?

List Medications:

7. Do you have or have you ever had the following diseases?

Heart Disease:

Lung Disease:

Kidney Disease:

Liver Disease:

8. Do you have asthma?

List Medications:

9. Have you ever had a severe neck injury?

Describe:

10. Have you ever been knocked out?

Describe:

11. Do you wear glasses or contact lenses?

12. Have you had a broken bone or fracture in the past 2 years?

Describe:

13. Have you ever injured your back?

Describe:

14. Do you have back pain?

15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?

Describe:

16. Do you have other physical conditions which cause pain?

Describe:

17. Detail any surgical procedures:

18. What are your goals for the next three months?

19. Have you had your body fat tested?

If yes, what percent is it?

20. Are you training for a specific event?
If yes, explain:

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

RELEASE
This release is entered into between the undersigned and Hart Boot Camp of Missoula, its officers, subsidiaries, affiliates, and executors in addition to the City of Missoula and Lolo County. The purpose of Hart Boot Camp of Missoula including Hart Adventure Boot Camp is to provide fitness instruction and coaching for various levels of athletes/individuals.

The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:

1. Acknowledges that Cindy Hart is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.

2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Hart Boot Camp of Missoula including Hart Adventure Boot Camp does not guarantee either good nor bad will occur nor guarantees the training advice given by Hart Boot Camp of Missoula including Hart Adventure Boot Camp will produce good nor bad results.

3. 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.

4. 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 elements of a natural environment, 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 Hart Adventure Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.

Hart Adventure Boot Camp shall not be liable for any injuries or damages to me, or subject to any claim , demand, injury or damages, whatsoever, including without limitation, those damages from acts of passive or active negligence on the part of Hart Boot Camp their officers, employees, or agents. I do hearby expressly forever release and discharge Hart Adventure Boot Camp from all such claims, demands, injuries, damages, actions, or causes of action. I acknowledge that I have carefully read this paragraph and fully understand that this is a waiver and release of liability .

Checkmark the following:
If Signing Up for Consecutive Months I Authorize Hart Adventure Boot Camp to Charge My Credit Card for Each Class.

I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence.

I will restrict my alcohol consumption during Boot Camp.

I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence.

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. Any violation 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. I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization.

I understand there is no refund policy, but I can receive a credit (for unused portion of camp) towards a future camp if I'm not able to complete the one I originally joined. Camp fees can not be used towards any other products or services provided by Hart Boot Camp.

It is my responsibility to insure that I am physically able to participate in this program. Only a doctor can advise me on my ability to participate. By my signature below, I am acknowledging that I have been given the opportunity to obtain that advice and that I have been advised that I can participate.

I will remember to set my alarm and be at camp on time.

I understand that diet and nutrition will effect my fitness goals and performance during boot camp.

I will bring a positive attitude, and expect to have fun!

Your signature will be required at the time of your evaluation and you agree to the terms now!

____________________
Signature
____________________
Printed Name
____________________
Date

I agree to all Terms and Conditions listed above

For More Information, Contact us at (406) 544-0395 or e-mail Cindy@HartBootCamp.com