Choose a time: 5:30am 9:30am

My Name:

Date of Birth(required): Month Day Year

Address:

City: State: ZIP:

Home Phone: Cell Phone:

Job Title: Work Phone:

Email:

Emergency Contact Name: Phone:

Current Fitness Level(use scale of 1-10):

My fitness main goal is:

My fitness goal in this camp is:

How did you hear about Code Pink Boot Camp?

If by referral please provide their name:

Attendance Options(check one):
5 Days Per Week ($299)
3 Days Per Week ($199)
Annual Pass 1-FULL YEAR $ 45% off when you register here now. 2008 Session will run 10 camps beginning January 14 - Dec. 19. Full Rate fee is $2990. YOUR CODE PINK PASS is only $1644.50. (Expires 1/14/08)

Medical History Questionnaire

All "yes" answers require a written explanation in the bottom text field.

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
Yes No

2. Do you take any prescribed medication on a permanent or semi-permanent basis?
Yes No

3. Do you have a seizure disorder (epilepsy)?
Yes No

4. Do you have diabetes; Type I (IDDM) or Type II (NIDM)?
Yes No

5. Have you ever been found to be anemic (low blood count)?
Yes No

6. Do you have High Blood Pressure (hypertension)?
Yes No

7. Do you have or have you ever had Heart Disease?
Yes No

8. Do you have or have you ever had Lung Disease?
Yes No

9. Do you have or have you ever had Kidney Disease?
Yes No

10. Do you have or have you ever had Liver Disease?
Yes No

11. Do you have or have you ever had asthma?
Yes No

12. Do you have or have you ever had severe neck injury?
Yes No

13. Have you ever been knocked out?
Yes No

14. Have you had a broken bone or fracture in the past 2 years? Yes No

15. Do you wear glasses or contact lenses?
Yes No

16. Have you ever injured your back?
Yes No

17. Do you have back pain?
Never
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?
Yes No

19. Do you have other physical conditions, which cause pain?
Yes No

20. Have you had any surgical procedures?
Yes No

21. Have you ever had your body fat tested?
Yes No

22. Are you training for a specific event?
Yes No

If you are unsure about the definition of any terms in this form, please email us to clarify. Do not assume.

What are your goals for the next three months?

PLEASE EXPLAIN ALL �YES� ANSWERS BELOW. PLEASE REFERENCE THE QUESTION NUMBER.