Ft Lauderdale Bootcamp Registration & Participation Release Waiver
First Name
Last Name
Street Address
Apt No.
City
Zip Code
Home Phone
Cell Phone
Email Address
Date of Birth
EMERGENCY CONTACT INFORMATION
Name
Phone Number
Relationship
PARTICIPANTS INFORMATION
Thank you.
Please depress the submit button
to send your registration information
You will then be redirected to the payment page.
Where 'Ordinary' becomes 'Extraordinary' by adding a little 'Extra'
Ft Lauderdale
954-667-6714
fitbodeeze@gmail.com
Please Re-enter Email
Age
Occupation
How did you hear about us?
Do you exercise regularly?
Do you feel you need nutritional guidance to help with achieving your goals?
MEDICAL HISTORY
Please indicate any medications or conditions that may impact your participation in a fitness program
Have you been diagnosed with any of the following. Please check all that apply.
Have you experienced any problems with your bones, joints, spine, ligaments; muscles or tendons? If yes, please explain.
CONSENT
Acknowledgment of risk and release of liability:
I understand that each person has a different capacity for participating in fitness activities, and I, hereby, willingly assume such risk of injury or health risk for myself and assume full responsibility for all risks of personal injury, illness, property damage, loss or death resulting from my participation in this program. I acknowledge my obligation to immediately inform the staff or instructor if I feel any pain, discomfort, fatigue, nausea or other symptoms that I may suffer during and immediately after my participation. I understand that I may stop participation at any time, and I may be requested to stop by staff or instructor who observes any symptoms of distress or abnormal response. In addition, I agree to waive all claims that I have or may have in the future against, ZOM Residential Services, Inc., ZOM Flagler Village, L.P., ProServe Concepts, Inc., Fit Bodeeze, Christine Sposa, as well as any staff members, instructors employed by them. I agree to hold them harmless from all liability, including any actions, proceedings, claims, damages, cost demands, including court costs with regard to my participation in this program. I authorize ProServe Concepts, Inc., Fitbodeeze, Christine Sposa, and professionals, in the event of emergency, to use its reasonable discretion on behalf of the undersigned in rendering first aid treatment and/or arranging for emergency care, at the expense of the undersigned.
UNDERSTANDING OF WAIVER
By clicking here, you are providing your consent and acknowledgement of your understanding of the participation waiver.
Month
Day
Year
Please provide additional details pertaining to any of the above conditions you have.
- I agree to the terms outlined in this waiver. I confirm that I have had sufficient time to read and understand each item and have agreed to the terms freely and voluntarily.
- I acknowledge that the information I provided is true and accurate and that I have not withheld any medical information.
If you are a returning client and your contact information has NOT changed, you may proceed directly to the Payment page.
Otherwise, please complete the Participant information form below.
