Specializing in the Busy Woman's Weight Loss, Nutrition and Lifestyle

14 Day Jump Start 5:30am M/W Battery Park Boot Camp

I WANT TO PERSONALLY THANK YOU FOR COMING ON BOARD!

Please fill out the form below to complete the registration process.

Once you click "Submit" you will be taken to a page with all of the details you will need to in order to start your program!

What camp are you joining?
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:
Emergency Contact
(Name and Phone Number)
|
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)
4. Do you have diabetes?
(adult or juvenile; list medications if applicable)
5. Have you ever been found to be anemic? (low blood count)
6. Do you have High Blood Pressure? (hypertension)
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?
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:
21. Please add any other information you would like for us to know about you.
Release

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 Miranda Fitness Concepts, INC, its officers, subsidiaries, affiliates, and executors in addition to the City of New York adn Oceanside, Long Island. The purpose of Miranda Fitness Concepts, INC 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 Miranda 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 Miranda Fitness Concepts, INC does not guarantee neither good nor bad will occur nor guarantees the training advice given by Laura Miranda including Miranda Fitness Concepts, INC 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, running 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 Miranda Fitness Concepts, INC 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 Miranda Fitness Concepts, INC including Laura Miranda 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. Customer client agrees to confidentiality with respect to Miranda Fitness Concepts, INC and all services provided by same.

The undersigned agrees that during participation in Miranda Fitness Concept's (MFC) boot camp/running camp program and for 18 months afterward, will not directly or indirectly participate in their own boot camp/running camp fitness business or as a co-owner, director, officer, consultant, independent contractor, or agent of another business. Boot Camp/Running Camp fitness business is defined as one that is similar to the business as operated by MFC, now or later, in the same geographical area of 10 miles from Oceanside, NY and 10 miles from the NYC locations.

In particular, undersigned agrees to not: (a) Solicit or attempt to solicit any business or trade from MFC's actual or prospective customers or clients; (b) Employ or attempt to employ any camper or employee of MFC; (c) Divert or attempt to divert business away from MFC; (d) Encourage any independent contractor or consultant to end a relationship with MFC.

Checkmark the following:
I agree not to use foul language during my program. Any violation will result in twenty push-ups per occurrence.
I agree not to eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of my program. Any violation will result in twenty push-ups per occurrence.
I agree to show up for my program every day unless it is an excused absence from my doctor or pre-approved with my program directors. Excused absences are the only ones eligible for make-up during the current camp and may not be carried over to following camp sessions. 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 my program, 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 will remember to set my alarm (or alarms) and be at camp on time.
I understand that diet and nutrition will effect my fitness goals and performance during my program.
I will bring a positive attitude, and expect to have fun!
Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature
Date (MM/DD/YYYY)