Medical History (If you are a returning camper, complete only the sections that have changed.)
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
No
Yes
If yes, list medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
No
Yes
If yes, list medications:
3. Do you have a seizure disorder (epilepsy)? No
Yes
4. Do you have diabetes (adult or juvenile)? No
Yes
If yes, list type and medications:
5. Have you ever been found to be anemic (low blood count)? No
Yes
6. Do you have High Blood Pressure (hypertension)? No
Yes
If yes, list medications:
7. Do you have or have you ever had the following diseases?
Heart Disease? No
Yes
Lung Disease? No
Yes
Kidney Disease? No
Yes
Liver Disease? No
Yes
8. Do you have asthma?
No
Yes
If yes, list medications:
9. Have you ever had a severe neck injury? No
Yes
If yes, describe:
10. Have you ever been knocked unconscious? No
Yes
If yes, describe:
11. Do you wear glasses or contact lenses? No
Yes
12. Have you had a broken bone or fracture in the past 2 years? No
Yes
If yes, describe:
13. Have you ever injured your back? No
Yes
If yes, describe:
14. How often do you have back pain?
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
No
Yes
If yes, describe:
16. Do you have other physical conditions which cause pain? No
Yes
If yes, describe:
17. Detail any surgical procedures:
18. Are you pregnant? No
Yes
19. What are your goals for the next three month?
20. Have you had your body fat tested? No
Yes
If yes, what percent is it?
21. Are you training for a specific event? No
Yes
If yes, explain:
Release
This release is entered into between the undersigned and Lisa Huck doing-business-as Central Coast Boot Camp, its officers, trainers, affiliates, and executors in addition to the City of San Luis Obispo and San Luis Coastal Unified School District. The purpose of Central Coast Boot Camp is to provide fitness instruction and coaching for various levels of athletes/individuals.
The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:
1. Acknowledges that Central Coast Boot Camp’s officers, trainers, affiliates, and executors are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Central Coast Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Central Coast Boot Camp 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, kung-fu, 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/activities including the inherent dangers of the natural elements, 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 and Central Coast Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.
The Undersigned agrees that this is the full agreement between the parties, that Central Coast Boot Camp 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 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 any “before & after” photos will not be used for any promotional purposes unless I give written authorization.
I understand that my success is determined by my attendance on the days I’ve committed to attend. I understand there is a "no refund" and no “make-up” policy.
By submitting this form electronically, you are representing all information on this form is true and correct.
