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What do I need to do now & liability release
Call 1.800.680.2803 and schedule your initial evaluation
Print Out & Complete all 7 pages
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We are by appointment only
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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7:15 -9 am
or
2:30 - 5:00 pm
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No Appts
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7:15 -9 am
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1:30 - 5:15 pm
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1:30 - 5:15 pm
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7:15 -9 am
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Please turn in all paperwork and payment to Molli & Tony arrive! at your Initial Evaluation
NOTICE: It is wise to seek your doctor’s advice before beginning any health or fitness program!
Congratulations on your choice to get fit and have fun!
Here are some important things to remember:
- · Unless otherwise instructed, bring your 5 lbs or 8 lbs hand weights, a yoga mat and water each day.
- · Avoid all four letter words except “Yeah!”
- · If you MUST miss a day, let Tony or Molli know before that day arrives!
- · Give 110% effort!
- · If you have an unusual ache or pain, tell Tony or Molli immediately!
- · You MUST have fun!!!
- · Running Shoes are the best shoes for camp. Not cross-trainers or walking shoes!
- · Avoid perfumes!
- · You must eat something simple & small before class. Bring a snack for your car to keep your blood sugar levels stable
- Note: YOUR PRE_ & POST_CAMP EVALUATIONS TAKE PLACE AT OUR OFFICE.
400 N Mountain Ave # 244 Upland, California 91786
Directions:
Cross Streets are Arrow Hwy. / Mountain Ave Located on the second floor above C21 Beachside
From the 10 Fwy. take the Mountain exit go North about 1 mile turn into the Mimi’s restaurant parking lot. We are located on the second floor above C21 Beachside, See you there.
From the 210 Mac take the Mountain exit go South to Arrow Hwy. and make a left hand turn onto Arrow Hwy. Make a quick right into the first parking lot and park in front of C21 Beachside Realtors. We Located on the second floor above C21 Beachside, See You There.
Your Boot Camp Adventure Begins
Promptly at: 5:30 am - 6:30 am for morning boot camp
Promptly at: 6:00 pm - 7:00 pm for evening boot camp
Arrive at least 10 minutes prior to class and begin walking to warm up
Actual Location: Call us 1.800.680.2803
All Boot Campers are responsible for knowing where camp will be held on any given day. If you have any questions as to where camp will be held call 909.510.8432 after 4:45 AM in the morning to listen to an automated voice mail message informing you where Camp will be held that day.
All attempts will be made to hold the camp outdoors _______________________________________________
* IMPORTANT NOTE: We will be taking role each morning. It is your responsibility to sign in each day as you arrive. Simply place a check mark next to the appropriate day. You are responsible for knowing about the special days in this camp and where to go.
REGISTRATION FORM 1.800.680.2803
Follow these instructions:
1. Print your information clearly or type.
2. Call to schedule your initial evaluation 800-680-2803
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 ___/___/___
Emergency Contact and phone number______________________
I'm signing up for the camp beginning on this date____/____/____.
The start time for my camp is ___ 5:30 AM ____6:00pm
This is my first camp ___ The last camp I attended was ____
Home Phone (_____)____________________
Work Phone (_____)_____________________
E-mail ________________@_______ I understand I will be emailed by IEABC______
I rate my current fitness level as a _____ (1-10), ten being high.
I was referred by ______________________________.
My main goal is to _____________________________________________.
Please check off packages you are interested in:
Option #1 - 3 days per week and full nutrition plan for $399 ______
Option #2 - 3 days per week boot camp only for $199 ______
We accept Visa and MC cash & checks.
Your payment is due in full at the pre-assement evaluation.
If Paying by check, please make payable to:
Inland Empire Adventure Boot Camp, Inc.
22897 Mariner Dr. Canyon Lake, California 92587
My card number is ___________________________________________________________
Expiration _____/_____ 3 Digit Code on back _____
Name on card _________________________________________
Billing address of Card ___________________________________________
Authorized signature ________________________
MEDICAL HISTORY--------------------------------------------------------------------------------
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2. Do you take any prescribed medication on a permanent or semi-permanent basis? If Yes, list__________________________________________________________ ___
3. Do you have a seizure disorder (epilepsy)? Yes No
4. Do you have diabetes Adult or Juvenile? 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 the following diseases?
Heart Disease: Yes No
Lung Disease: Yes No
Kidney Disease: Yes No
Liver Disease: Yes No
8. Do you have asthma? Yes No
9. Have you ever had a severe neck injury? Yes/No Describe:
10. Have you ever been knocked unconscious? Yes/No Describe:
11. Have you had a broken bone or fracture in the past 2 years? Yes/No Describe:
12. Have you ever seriously injured your back? Yes/No
How often do you experience back pain? Never / Seldom / occasionally / frequently with vigorous exercise or heavy lifting Describe:
13. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:
14. Do you have other physical conditions which cause pain or would preclude you from attending Boot camp? Yes/No If Yes, Please Describe:____________________________________
*Gentlemen skip questions 15 and 16.
15. Are you pregnant? Yes/No
16. Did you have a baby within the last 6 months? If so when? _______________
17. Detail any surgical procedures:
18. Have you had your body fat tested? If yes, what percent is it?
19. Are you training for a specific event? If yes, explain:
20. What specifically do you want to accomplish during your first camp? ________________________________________________
________________________________________________
21. What programs and diets have you participated in, in the past? ______________________________________________________
________________________________________________
22. Which of those programs worked for you and which didn’t? ______________________________________________________
________________________________________________
23. What are you willing to do different this time? What are you willing to change in order to get the results you are after? ______________________________________________________
________________________________________________
Initial the following:
______ I agree that I will not consume alcohol during the boot camp. Any violation will result in twenty push-ups per occurrence.
______ I agree not to use foul language during boot camp. Violations will result in twenty push-ups per incident
______ I agree not to eat or say the words Twinkie, Krispy Kreme donuts, frappucinos, french-fries, pizza, ice cream, Slurpies, chocolate bars, chips, pies, pastries, Ho-Ho's, Ding Dongs, or cupcakes 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 with the exception of the Results Guarantee Enrollment only available at my Pre-Camp Evaluation, but I can receive a credit (for unused portion of camp) towards a future camp, at Molli and Tony’s discretion, if I'm not able to complete the one I originally joined. Camp fees cannot be used towards any other products or services provided by Molli & Frederick “Tony” Rathstone or Inland Empire Boot Camp.
______ I will remember to set my alarm and be at camp ON TIME.
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. The undersigned herby indemnify, defend with counsel acceptable to Forest City Commercial Management, Inc., acting as authorized agent for Victoria Gardens, and hold harmless Forest City Commercial Management, Inc., acting as authorized agent for Victoria Gardens and Owners, and their principals, officers, directors, agents, employees, mortgagee(s), ground lessors, associated business entities, and all of their heirs, predecessors, successors and assigns from and against all legal actions, liabilities, obligations, damages, penalties, claims, cost, charges and expenses, including reasonable attorneys' fees which may arise in any manner out of Inland Empire Adventure Boot Camp, Inc. use, operation or maintenance of the Inland Empire Adventure Boot Camp, Inc. area or the Center and/or in connection with loss of life, bodily or personal injury or property damage arising from or out of all acts, failures, omissions or negligence of Inland Empire Adventure Boot Camp, Inc., its agents, employees or contractors which occur in, on or about the Empire Adventure Boot Camp, Inc. area, unless such legal action, damage, loss, liability or other expense (including attorneys' fees) results from any sole act, omission or neglect of Forest City Commercial Management, Inc., acting as authorized agent for Victoria Gardens, its agents, contractors, employees or persons claiming through it or them.
10. 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.
11. 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 Guardians Signature
_______________________________
PRINT Parent or Guardians Name
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