Women and Men's Adventure Fitness Boot Camp in Napa, bootcamp for women and men, adventure boot camp, womens and men fitness program, womens and men weight loss, exercise camp, womens and men camp, exercise, workout programs, outdoor exercise

Boot Camp Registration

North Bay Adventure Boot Camp
REGISTRATION

You now have 2 options:
A. You can print this form and send it in with payment by mail
B. Register Online
Fill out the online form below to register via internet. Click on Submit to go to the payment page.
Payment Page: Pay via Paypal. Choose your class and finish your online registration

NOTE: We cannot guarantee your space will be reserved if you do not supply us with payment information on this form if sending via internet.

If paying by check, please make check out to:
Napa Adventure Boot Camp
1047 Kansas Avenue
Napa, CA 94559
info@napabootcamp.com
Phone 707-225-2490

Registration Form
You will be notified to schedule your pre-camp evaluation (if needed for your program).
Please note: Areas in yellow are required.
Personal Information
Name		Address
City		State / ZIP	/
Profession		Country
Date of Birth	(mm/dd/yyyy)	Phone Number
Work Number		Fax Number
Email Address

Self Assessment & Additional Information
I rate my current fitness level as a (1-10), ten being high.
I was referred by:
How did you hear about us?:
Please specify publication / website / friend or other referral:
This is my first camp:
If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number	\|

Camp and Payment Information
Please select your camp location, number, time, days per week you are attending and let us know if you are signing up for multiple camps. Required
What camp are you joining?
What time are you attending?
Multiple Camp Registration:
Form of payment:
$299 (5 days/week) \| $199 (3days/week) This option is for those who have other commitments in the early a.m. Since it is only a 4-week class, we do prefer you to attend the full 5-day a week program for best results and overall work-out! You can do it! Note: If paying by check, please print this online form and mail or fax it in with payment. *Please note - we cannot guarantee your reserved spot until payment is received.

Credit Card Information
For security reasons, your credit card information is not stored or saved within our system. Your credit card information is required at this time to process your registration. PLEASE verify all credit card numbers are entered before sending.
*Credit Card Number (No Spaces):*
Expiration Date:	/
Name on Credit Card:
*CVC Code:**	* (security code)
Visa and MasterCard In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a special 3 digit code. This 3 digit code is your CVC. American Express On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code.

Medical History
(If you are a returning camper, only complete the sections that have changed.)
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
List Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
List Medications:
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes Adult or Juvenile?
List Medications:
5. Have you ever been found to be anemic (low blood count)?
6. Do you have High Blood Pressure (hypertension)?
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:
8. Do you have asthma?
List Medications:
9. Have you ever had a severe neck injury? Describe:
10. Have you ever been knocked out? Describe:
11. Do you wear glasses or contact lenses?
12. Have you had a broken bone or fracture in the past 2 years? Describe:
13. Have you ever injured your back? Describe:
14. 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? Describe:
16. Do you have other physical conditions which cause pain? Describe:
17. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat tested?
If yes, what percent is it?
20. Are you training for a specific event? If yes, explain:

Release
Informed Consent, Waiver, and Release Agreement This waiver and release is entered into between the undersigned and Sonoma Valley/Napa Valley Adventure Boot Camp / Total Body Balance / Jeffrey D. Larson Jr. Enterprises, Inc. its instructors, officers, affiliates, and executors. The purpose of the Adventure Boot Camp Program offered by Jeffrey Larson is to provide fitness instruction and coaching for various levels of athletes/individuals. The undersigned hereby acknowledges that the following was explained to me and/or agree to the following: Acknowledges that the instructor is not a physician and is not trained in any way to provide medical diagnosis or any other type of medical advice. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but Napa Valley Adventure Boot Camp and Jeffrey D. Larson, Jr. Enterprises, Inc. does not guarantee neither good nor bad will occur, nor guarantees the training advice given by Sonoma/Napa Valley Adventure Boot Camp and Jeffrey D. Larson, Jr. Enterprises, Inc. or its instructors will produce good nor bad results. 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. 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 and activities, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. Acknowledges that it is recommended to consult a physician prior to starting any health/fitness/nutrition program. Boot Camp client shall not, after completing boot camp, engage directly or indirectly, either personally or as an employee, associate partner, partner, manager, agent or otherwise, or by means of any corporate or other device, in the outdoor fitness or boot camp fitness business within Napa County, Sonoma County or Solano County. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Skyline Park/ County of Napa/ Napa Valley Adventure Boot Camp / Sonoma Valley Adventure Boot Camp/ City of St. Helena/ St. Helena Hospital Women's Center/ First Baptist Church/ Hanna Boys Center/ Old Adobe Union School District/ Jeffrey D. Larson, Jr. Enterprises, Inc., its instructors, officers, affiliates, and executors 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 neither representatives of Napa/Sonoma Valley Adventure Boot Camp or Jeffrey D. Larson, Jr. Enterprises, Inc. nor anyone else has 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 . PERFORMANCE PLEDGE In the spirit of harnessing your best effort and providing optimum results from your Boot Camp experience, we have established the following policies to which you will need to adhere. Please read and initial each one.
Checkmark the following:
	I agree to be coachable/trainable during my 4 weeks of boot camp in order to achieve by health and fitness goals.
	I am making a commitment to myself to change my lifestyle for better health & self improvement.
	I choose to commit to eating and drinking foods and beverages that will accelerate my success.
	I commit to give 100% effort to myself and my fitness at each class and the remaining 23 hours per day.
	I commit to respect my coach and my peers by not talking while the coach is instructing. If the coach is speaking it is likely information that my peers and I need to hear to make our boot camp experience more safe and effective.
	I agree to show up for Boot Camp every day that I have registered for.
	Any violation of the above statements will result in the client performaning the “Commitment Circuit”.
	I understand that photos or video may be taken during the camp, which may be used for promotional purposes.
	I understand there is NO REFUND after the camp I have registered for begins. No exceptions – don’t ask. If you are unable to begin the camp you have registered for you may cancel before camp begins, there will be a $50 cancellation fee.
	I understand I can only receive a credit (for unused portion of camp) towards a future camp if, for reasons beyond my control, I am not able to complete the one I originally joined. If I expect to received credit I must inform NVABC in writing at least 24 hours prior to missing class. Camp fees cannot be used towards any other products or services provided by Jeffrey D. Larson, Jr. Enterprises, Inc

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)

For More Information, Contact us at (707) 265-6218 or e-mail info@napabootcamp.com

Calendars: Napa | Napa at St. Helena | Santa Rosa | Sonoma || Registration: New Campers | Returning Campers