Location of Camp:

Choose a time: 5:30am 9:00am 6:30pm

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)

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.

Informed Consent, Waiver, and Release Agreement

This waiver and release is entered into between the undersigned and CODE PINK Boot Camp / Christina Lucy Co. its instructors, officers, affiliates, and executors.

The purpose of the CODE PINK Boot Camp Program offered by Christina Lucy Co. 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:

1. 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.

2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but CODE PINK Boot Camp and Christina Lucy Co. does not guarantee neither good nor bad will occur, nor guarantees the training advice given by CODE PINK Boot Camp and Christina Lucy Co. or its instructors 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, 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 and activities, 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 Code Pink Boot Camp, its instructors, officers, affiliates, and executors for the undersigned participating in said sporting events and/or training.

The Undersigned agrees that this is the full agreement between the parties, that no representatives of CODE PINK Boot Camp or Christina Lucy Co. 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 CODE PINK Boot Camp experience, we have established the following policies to which you will need to adhere. Please read each one. By clicking through with your registration, you show that you agree.

I agree that I will not consume alcohol during the month of Boot Camp.

I agree not to use 4-letter words during Boot Camp, except Yeah!

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 to 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. I understand that my "before & after" are an option I may choose. "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, for reasons beyond my control, I am not able to complete the one I originally joined. Camp fees cannot be used towards any other products or services provided by CODE PINK Boot Camp or Christina Lucy Co.