Pacific Northwest Boot Camp, Eastside Adventure Fitness Boot Camp - Issaquah, Bellevue, Fall City, North Bend, Snoqualmie, Carnation, Preston, Redmond, Newcastle, Kirkland

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Secure Eastside Boot Camp Registration Form

Use this online form if you are paying by credit card only.
If you want to mail in/fax in your form, click on the appropriate form to download:

NOTE: We cannot guarantee your space will be reserved if you do not supply us with payment information on this form.

Email Address:
Full Name:
Street Address:
City:
State:
Zip Code:
Date of Birth, Please include Year:
Profession:
Best Contact Phone Number w/area code (i.e. cell phone):
I rate my current fitness level as: (Ten being high)
*Please tell us how you heard about us:*
Camp Date/Program Registering for:
Special Camp Code: (if applicable)
Camp Days per week:
Camp Time:	5:30 - 6:30 a.m. 9:15 - 10:15 a.m.
Camp Location attending:
This is my first camp:	Yes No
If you answered "no" - when was the last camp you attended?
Emergency Contact Name and Phone #:
Note: If paying by check, do not use this online form. *Please download the mail-in form above.* 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.
I will be paying by:	Mastercard Visa American Express Discover PayPal
*If paying with PayPal, name on account* (if different than above):
Credit Card Number:
Exp Date:
Name as it appears on Card:
CVC Code* on back of Credit Card:
Billing address of Credit Card if different than above address:
Visa & Mastercard In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a 3-digit code. This is your CVC. American Express* On the front of your card next to your main credit card number look for a 4 digit code. This is your Card Security Code. MEDICAL HISTORY: If you are a returning camper and have no medical changes, the section below does not need to be completed. ALL Campers, Please check the Terms and Conditions Box before you Submit - Thank You, I look forward to seeing you in camp!
1. Are you allergic to any medication, food or bug bites? Please list:
2.Do you take any prescribed medication (permanent/semi-permanent)? Please list:
3. Do you have a seizure disorder (eplilepsy)?	Yes No
4. do you have diabetes?	Yes No
If yes to above, please list medications:
5. Do you have asthma?	Yes No
6. do you have High Blood Pressure (hypertension)?	Yes No
If yes to above, please list medications:
7. do you have or have you ever had the following diseases? (check all that apply)	Heart Disease Lung Disease Kidney Disease Liver Disease
8. Have you ever been found to be anemic (low blood count)?	Yes No
9. Have you ever had a sever neck injury? If Yes, please describe:
10. Have you ever been knocked out? Please describe:
11. Do you wear glasses or contact lenses?	Yes No
12. Have you had a broken bone or fracture in the past 2 years? Please describe:
13. Have you ever injured your back?
14. do you have back pain?	Never Seldom Occasionally Frequently Only with vigorous exercise or heavy lifting
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Please describe:
16. Do you have other physical conditions which cause you pain? Please describe:
17. Please detail any surgical procedures:
18. Please describe your GOALS for the next 3-months and WHY?
19. What is your T-shirt size?
RELEASE: This release is entered into between the Undersigned and Eastside Adventure Boot Camp, L.L.C., its officers, affiliates and executors in addition to the City of Snoqualmie, and the county of King. The purpose of Eastside Adventure Boot Camp, L.L.C. is to provide fitness instruction and coaching for various levels of athletes/individuals. Note: We reserve the right to refuse the participation in camp, if the instructor feels that the safety of the group or individual would be in jeopardy. By agreeing to this release, the registering party hereby acknowledges that the following was explained to me and/or agree to the following: 1. Acknowledges that Kimbrough Kendall, 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 Eastside Adventure Boot Camp, L.L.C. instructors, support staff, and affiliates are not physicians and is not trained in any way to provide medical diagnosis or any other type of medical advice. 3. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but Eastside Adventure Boot Camp, L.L.C. does not guarantee neither good nor bad will occur, nor guarantees the training advice given by Eastside Adventure Boot Camp, L.L.C. will produce good nor bad results. 4. Acknowledges that the registering party 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. 5. Acknowledges that boot camps, aerobic classes, martial arts, kick-boxing, kung-fu, running, weight training, obstacle courses, and any other related sports/activities 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 for participating in these types of events/activities, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. I agree to show up for Eastside Adventure Boot Camp every day unless it is an excused absence from my doctor or approved by my Boot Camp director. I understand there is NO REFUND policy, but I can receive a credit (for the unused portion of the camp) towards a future camp if I’m not able to complete the one I originally joined. Eastside Adventure Boot Camp fees cannot be used towards any other products or services. I understand that photos or video may be taken during the course of my involvement in Eastside Adventure Boot Camp, which may be used for promotional purposes. I understand that my “before and after” photos will not be used for any promotional purposes without my express written consent. I understand that diet and nutrition will effect my fitness goals and performance during boot camp. I will remember to set my alarm and be at camp on time! By checking the box to agree to all terms and conditions, I expressly waive, release, discharge, and relinquish Eastside Adventure Boot Camp, L.L.C. and Kimbrough Kendall from any and all causes of action, including any liability of death, disability, personal injury, or action of any kind, that may arise out of my participation in Eastside Adventure Boot Camp, L.L.C. activities or events and/or training for such activities or events.
Yes, I have read and agree to all terms and conditions.