Form

Step 1 : Max Body Boot Camp Registration Form
First Name*
Last Name*
Email*
Phone Number*
Address*
City*
State*
Date of Birth (MM/DD/YY)*
Height
Weight (Current)
Tell me a little bit about your goals...
Is this your first camp?*

Yes No
What date are you joining?*
What camp time are you signing up for?*
Were you referred to us?*

Yes No
If yes, by who?
Health History (New Campers Only)
If you are a returning camper and your health history has not changed, than you do not need to fill out this section.
Have you exercised in the past 6 months?

Yes No
Type of exercise and duration:
Are you dieting?

Yes No
Type of diet:
Eating habits:
Do you smoke?

Yes No
If yes, how many cigarettes or packs per week?
Do you drink?

Yes No
If yes, how many drinks do you have per week?
Please list any medications you are taking:
Please check if you have or have had any of the following:

Heart attack Heart trouble Coronary bypass surgery Chest pain or angina Angioplasty High cholesterol Difficulty breathing Irregular heart beat/rhythm Cardiac catheterization High blood pressure Stroke Convulsions Asthma limitations of movement Back problems/surgeries Abnormal stress test Low blood pressure Diabetes Loss of consciousness MS Knee problems/surgeries Shoulder problems/surgeries
If you answered yes to any of the above questions, please explain in further detail:
Emergency Contact*
Emergency Number*
(By submitting this form you, are agreeing to all of the above!)
Should be Empty:

Step 1 : Max Body Boot Camp Registration Form