Norwalk Boot Camp

Click here to review our privacy policy!

You now have two options:
1. You can print this form and send it in by fax or mail, or
2. Click here to register immediately "SECURE" online.
NOTE: We cannot guarantee your space will be reserved if you do not supply us with credit card information on this form.

If you chose option one, follow these instructions:

1. Print your information clearly or type
2. Fax to (203) 604-0832 or mail to:
c/o Laura Krout
100 Richards Ave. #405, Norwalk, CT 06854
If you are paying by check, please make payable to BK Wellness Enterprises.
3. You will be notified to schedule your pre-camp evaluation (if needed for your program).

Profession: _________________________________
Email: _________________________________
Date of Birth ___/___/___

Home Phone (_____)____________________  
Work Phone (_____)_____________________
Fax Number (___)_______________________
E-mail _________________@_____________
I rate my current fitness level as a   _____ (1-10), ten being high.
How did you hear about us? ______________________________________________________________________.
Emergency Contact and phone number______________________________________________________

If you need to provide credit card information: (circle one)     MasterCard    Visa    otherwise ignore this section.
Name on the Card:  
Credit Card Number:  
Card Expiration Date:  
CVC Code*  
Your Signature:  

*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.

What is the name, location & time of the program you are joining?

__________________________________________________ Price of program $ _____

If paying by check, please make payable to BK Wellness Enterprises, Inc.
100 Richards Ave. #405, Norwalk, CT 06854.  Waiver must be signed prior to participation.

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

 3. Do you have a seizure disorder (epilepsy)? Yes No
 4. Do you have diabetes Adult or Juvenile? Yes No

List Medications:
5. Have you ever been found to be anemic (low blood count)? Yes No
6. Do you have High Blood Pressure (hypertension)? Yes No
 List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease: Yes No
Lung Disease: Yes No
Kidney Disease: Yes No
Liver Disease: Yes No
8. Do you have asthma? Yes No
List Medications:
9. Have you ever had a severe neck injury?
10. Have you ever been knocked out?
11. Do you wear glasses or contact lenses? Yes No
12. Have you had a broken bone or fracture in the past 2 years?
13. Have you ever injured your back?
14. Do you have back pain?
Never    Seldom    Occasionally    Frequently with vigorous exercise or heavy lifting
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
16. Do you have other physical conditions which cause pain?
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:
 NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

This release is entered into between the undersigned and BK Wellness Enterprises, its officers, subsidiaries, affiliates, and executors in addition to the City of Norwalk. The purpose of BK Wellness Enterprises is to provide fitness instruction and coaching for various levels of athletes/individuals.

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

 1. Acknowledges that Laura Krout is not a physician 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 BK Wellness Enterprises, LLC does not guarantee neither good nor bad will occur nor guarantees the training advice given by BK Wellness Enterprises, LLC 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, 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/activities including the elements of a natural environment, 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 BK Wellness Enterprises, LLC 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 BK Wellness Enterprises, LLC. 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.

Printed Name