Fighting Fit BootCamp Registration Form

First Name

Last Name

Address - Street Number

Street Name

City & Postal Code

Home Telephone Number

Cellular Telephone Number

Date of Birth

Email Address *

Please note that this will only be used to send you notices about the camp. Your information will be kept confidential and will not be given to other compay's.

Emergency Contact Name & Telephone Number

Health Card Number

Boot Camp Start Date (please see calendar on website)

2 days a wk/6wks = $199.95 + 13% GST

Please rate your current Fitness Level on a scale from 1- 10, where 10 is an elite athlete.

What are you overall fitness goals?

What is your goal (s) for this specific camp?

Do you have any pre-existing medical conditions that we should be aware of?

Are you currently taking any medications? If so, please list below:

Do you have any injuries or suffer from pain, that we should know about?

Do you consider yourself to be active?

Yes No

On a weekly basis, how often do you exercise?

Please list the type of exercises you enjoy!

Is there any reason why you cannot exercise on a regular basis?

Please rate your stress levels on a daily basis.

Low Moderate High

How many hours of sleep do you get on an average night?

5 - 6 Hours 7 - 8 Hours 9 + Hours

Do you smoke?

Yes No

What is your current weight?

What is your ideal weight?

Do you follow a special diet?

Yes No

How would you rate your eating habits?

Poor Ok Good

Is weight loss one of your primary exercise goals?

Yes No

All information will be kept confidential.

Will you require boxing gloves? Cost is $40.00

Yes No

All information will be kept confidential.

How will you be paying?

PayPal Cheque Cash

Were you referred by one of our previous Camp participants? If so, please let us know who.

How did you hear about us? Our Newsletter, CHEZ 106, Automobile Advertising, Customer Referral, Orleans Star/Journal, The Now EMC or Internet Advertising?

Wufoo