*** NEXT BOOTCAMP ***

Starts September 5th!!!!

Secure Registration

>>>click here<<< to review our privacy policy!

Use this online form if you are paying by credit card only.
If you want to mail in/fax in the form, >>>click here<<<

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

* Indicates a required field.

You will be notified to schedule your pre-camp evaluation (if needed for your program).
*First Name
*Last Name
*Address Please, no #'s, only dashes or periods allowed
*City
*State
*ZIP
*Profession
*Date of Birth mm/dd/yy (Please enter the slashes)
*Phone Number Work Number
Fax Number  
*Email Address
*I rate my current fitness level as a (1-10), ten being high.
How did you hear about us? :
*This is my first camp: Yes | No If you answered "no", when was the last camp you attended:
*Name of Emergency Contact & Phone Number
*What is the location/date of the program?
What program are you joining?    

*Credit Card:

 

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. If you are paying by check, please click here to be redirected to the mail in/fax form.

*Credit Card Number

*Exp Date:  / 
*Name on Credit Card *CVC Code*:

*Visa and Mastercard: In the signature box on the back of your card you should see at least the last 4 digits of your credit card number followed by a special 3 digit code. This 3 digit code is your CVC code.

MEDICAL HISTORY  (If you are returning and have no medical changes, the questions below do not need to be completed.) All Agreements remain the same.

*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)?
List Medications:  
*4. Do you have diabetes Adult or Juvenile?
*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?

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

RELEASE
This release is entered into between the undersigned and BKWellness Enterprises LLC, its officers, subsidiaries, affiliates, and executors in addition to the City of Norwalk. The purpose of Norwalk Adventure Boot Camp 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:

1. Acknowledges that Laura Boniello-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 Norwalk Adventure Boot Camp including Norwalk Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Norwalk Adventure Boot Camp including Norwalk Adventure Boot Camp 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 Norwalk Adventure Boot Camp 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 Norwalk Adventure Boot Camp including Norwalk Adventure Boot Camp 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.

Checkmark the following:
*I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence.

*I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence.

*I agree to show up for Boot Camp every day unless it is an excused absence from my doctor or pre-approved with Boot Camp directors. Any violation will result in twenty push-ups per occurrence.

*I understand that photos or video may be taken during the course of my involvement in Boot Camp, which may be used for promotional purposes. I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization.

*I understand there is no refund policy, but I can receive a credit (for unused portion of camp) towards a future camp if I'm not able to complete the one I originally registered for. Camp fees can not be used towards any other products or services provided by Norwalk Adventure Boot Camp.

*I will remember to set my alarm and be at camp on time.

*I understand that diet and nutrition will effect my fitness goals and performance during boot camp.

*I will bring a positive attitude, and expect to have fun!

By submitting this form I agree to all Terms and Conditions listed above