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AB MILLER FUNDRAISER 1.800.680.2803
What do I need to do now & liability release
Print Out & Complete all 4 pages
Please turn in all paperwork and payment to AB Miller Basketball Coach John Romagnoli by Monday, October 23rd
NOTICE: It is wise to seek your doctor’s advice before beginning any health or fitness program!
Name:______________________________________ Street:______________________________________ City:_______________________________________
Zip Code:_______________
Profession: ______________________________
Date of Birth ___/___/___
The best number to contact me at (___)____________
Emergency Contact and phone number________________
I'm signing up for the camp taking place on this date: ____/____/___.
We are raising funds for _________________________________________
Yes I would like to be added to your free monthly E-mail Get Fit newsletter My email address is: _________________@_________ WE DO NOT RENT OR SELL YOUR INFORMATION
I have enclosed a check made out to “Inland Empire Adventure Boot Camp, Inc in the amount of $25 dollars._____ (we do not accept cash)
Or
I’m paying by credit card (Visa or Master card) Did you pay online? yes no
My card number is ___________________________________________________________
Expiration _____/_____ 3 Digit Code on back _____
Name on card _________________________________________
Billing address of Card ___________________________________________
Authorized signature ________________________
I will be charged $25 and the charge will show on my bill as Inland Empire Boot Camp.
Please continue there is more info to fill out.
Thank you for allowing us to be your fundraising choice. Inland Empire Boot Camp is committed to educating the community in regards to health and fitness. We want this to be the most fun, you’ve had, raising money for your team or organization.
Please help us out by choosing a category below. This will help to insure you have an enjoyable experience.
_____ (HOT SALSA)
I work out regularly 4 or more times a week and am very interested in being pushed, Bring it on Baby!
_____ (MEDIUM SALSA)
I work out, when I get the chance, usually 2-3 times a week. I am interested in taking my workout to the next level.
_____ (MILD SALSA)
Workout! What’s a workout? I have a really good sense of humor, but I’m not that interested in exercise. I’m just here to show support and obviously I’ll do anything for the team!
What you need to bring to camp
- · Please wear clothes and shoes you can workout in and don’t mind getting dirty.
- · Please bring water! And a good attitude. That’s all you need. (Assuming your paperwork is already turned in.)
- · Please use common sense. This is a workout program. If you have a medical condition that limits you in anyway. This program is not for you. Also if you are pregnant or had a baby less then 8 weeks ago, you may not participate. We greatly appreciate your interest in the program and would be happy to work with you one on one.
- · Be ready to work out and have a great time!
- Location:_______________ Time:______ Date:__________
If you have another group you would like to raise funds for, feel free to contact us @ 1-800-680-2803, ask for Tony. On the next page you will find the liability waiver, this must be signed and turned in with your payment in order for you to participate.
Liability Waiver and Photo Release Form
This release is entered into between the undersigned and Inland Empire Adventure Boot Camp, Inc. The purpose of Inland Empire Adventure Boot Camp, Inc. is to provide health and fitness instruction.
The undersigned hereby acknowledge that the following was explained to them and/or agrees to the following:
1. Acknowledges that Inland Empire Adventure Boot Camp Inc. nor Molli & Frederick “Tony” Rathstone or the employees and contractors working for either one are not a physician and are not trained in any way to provide medical diagnosis, medical treatment, psychotherapy, or any other type of medical advice.
2. Acknowledges that fitness training is another tool for teaching individuals about themselves, but that Inland Empire Adventure Boot Camp Inc. does not guarantee neither good nor bad will occur nor guarantees the coaching advice given by Inland Empire Adventure Boot Camp Inc. will produce good nor bad results.
3. That I am participating in the Health & Fitness Classes, Programs, or Workshops offered by Inland Empire Adventure Boot Camp Inc. during which I will receive information and instruction about health and fitness. I recognize that fitness programs require physical exertion which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.
4. The undersigned acknowledges that Inland Empire Adventure Boot Camp Inc. nor Molli & Frederick “Tony” Rathstone or the employees and contractors working for either one may suggest exercise as part of my fitness program/lifestyle management. I further understand that swimming, cycling (on and off road), in-line skating, triathlon, weight training, aerobic classes, martial arts, kick boxing, 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, 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 Inland Empire Adventure Boot Camp Inc. nor Molli & Frederick “Tony” Rathstone or the employees and contractors working for either one Inland Empire Adventure Boot Camp Inc. nor Molli & Frederick “Tony” Rathstone or the employees and contractors working for either one for the undersigned participating in said sporting events and/or training for said sporting/fitness activities.
5. In consideration of being permitted to participate in the Health & Fitness Classes, Programs, or Workshops, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the program.
6. In further consideration of being permitted to participate in the Health & Fitness Classes, Programs, or Workshops, I knowingly, voluntarily, and expressly waive any claim I may have against Inland Empire Adventure Boot Camp Inc. for injury or damages that I may sustain as a result of participating in the program.
7. I, my heirs, or legal representatives’ forever release, waive, discharge, and covenant not to sue Adventure Boot Camp, Molli & Frederick “Tony” Rathstone or the employees and contractors working for either one for any injury or death caused by their negligence or other acts.
8. I understand that is my responsibility to consult with a physician prior to and regarding my participation in the Health & Fitness Classes, Programs, or workshops. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the Exercise Classes, Health Programs, or Workshops.
9. Photo release: In connection with my participation in the Inland Empire Adventure Boot Camp Inc. Health & Fitness Classes, Programs, or Workshops, I consent to the use of my photograph or other likeness in the promotional and other materials of Inland Empire Adventure Boot Camp Inc. without payment or other consideration made to me.
10. The Undersigned agree that this is the full agreement between all parties and that Inland Empire Adventure Boot Camp Inc. nor Molli & Frederick “Tony” Rathstone or the employees and contractors working for either one nor anyone else has not 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.
I have read the above informed consent, waiver of liability, and photo release and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
_______________________________ Date _______
Participants Signature
_______________________________
PRINT Participants Name
_______________________________ Date _______
Parent or Guardian’s Signature
_______________________________
PRINT Parent or Guardian’s Name
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