MFP XFBC New Registration

Name *

Prefix First Last Suffix

Name of Parent or Guardian

Home Phone Number

### - ### - ####

Cell Phone Number
(text friendly)

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Home Phone Number

### - ### - ####

Cell Phone Number
(text friendly)

### - ### - ####

Email *

Please provide an email you check personally where you will receive our Welcome to MFP, preparation details and billing information.

Emergency Contact Name and Phone Number *

How did you hear about us? *

If referral, who referred you?

Please choose which Xtreme Fitness Boot Camp schedule you'll be attending.

XFBC
Lompoc Sched #1
5pm Mon, Wed & Fri
*1 Hr

Lompoc Sched #1
5pm Mon, Wed & Fri

VIP Package
3 Consecutive Boot Camps

T-Shirt Size: *

Small

Medium

Large

X-Large

2X-Large

3X-Large

4X-Large

Returning Boot Camp MFPer

Which method of payment do you prefer.

Payment Method *

Full payment - Cash - Payment must be paid on or before first training day. Please bring exact amount. No Exceptions!

Full payment - PayPal (No PayPal Account Necessary) Payment must be paid on or before first training day. No Exceptions!

Payment Plan - Cash ($10 Extra Fee Applies) All payments must be made on or before last training day to prevent late fee charges.

Payment Plan - PayPal - No PayPal Account Necessary ($10 Extra Fee Applies) All payments must be made on or before last training day to prevent late fee charges.

Full Payment - Pay by check - Payment must be paid on or before first training day. No Exceptions!

Payment Plan - Pay by check - ($10 Extra Fee Applies) All payments must be made on or before last training day to prevent late fee charges.

Make checks payable to: Mannys Fitness Program
Address: 909 East Bush Ave Lompoc Ca

Do you know anyone who would be interested in our boot camp program? A $25 discount applies with referral: *

Yes

No

I am referring: Name

First Last

Phone Number

### - ### - ####

Email

How would you rate your current fitness level (10 being best and 1 being worst):

What is your main fitness goal? *

Are you training for an event such as a future career, race, reunion, wedding etc?:

Yes

No

If so, what is it?

When is it?

MM / DD / YYYY

What is your current Profession? *

Date of Birth *

MM / DD / YYYY

Fitness Background Comments

Returning MFPer

If you are returning and have no medical changes, the medical section below does not need to be completed. All agreements remain the same. NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

Are you allergic to any medications?

Do you take any prescribed medication on a permanent or semi-permanent basis?

Do you wear glasses or contact lenses?:

Yes

No

Do you have or have you ever had the following:

Diabetes

Asthma

Anemia

High blood pressure (hypertension)

Seizure disorder (epilepsy)

Heart disease

Lung disease

Kidney disease

Liver disease

How many hours do you regularly sleep at night? # *

Height? ft' in" *

Current Weight? lbs *

Have you ever been knocked out? Describe:

Have you had a broken bone or fracture in the past 2 years? Describe:

Have you ever had a severe neck injury? Describe:

Have you ever injured your back? Describe:

Do you have back pain?:

Never

Occasionally

Frequently w/ vigorous exercise or heavy lifting

Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe:

Do you have other physical conditions which cause pain? Describe:

Detail any surgical procedures:

Adult Boot Camp ONLY

Do you smoke? If yes, how much? *

Do you drink alcohol? If yes, how many glasses? *

RELEASE

This release is entered into between the undersigned and Mannys Fitness Program. The purpose of Mannys Fitness Program is to provide fitness instruction, motivation and coaching for various levels of individuals.

The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:

1. Acknowledges that Manny is not physicians and is 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 Mannys Fitness Program does not guarantee neither good nor bad will occur nor guarantees the training advice given by Mannys Fitness Program 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, 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 Mannys Fitness Program 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 Mannys Fitness Program 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.

Contract Aggreement:
Attendance *

I agree that if I am taking advantage of MFP Boot Camp that I must attend all training days for which I am registered unless excused in a timely manner.

Contract Aggreement:
Photos and Video Consent *

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.

Contract Aggreement:
Refund Policy *

I understand there is no refund policy. By signing up for camp I am making a commitment to myself. I am committed to a fit and healthy lifestyle. I understand that MFP Boot Camp will accept no excuses for my failure to fulfill my commitment.

Contract Aggreement:
Cancellation System Rejection Fee *

I understand that by submitting my registration all information will be filed systematically and any cancellation will result in a $20 system rejection fee. Please read our Registration Policy.

Your signature will be required at the time of your evaluation and you agree to the terms now! This is a legal electronic contract therefore legal actions are activated upon submission.