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North Pinellas & Westchase Adventure Boot Camp for Women
Registration

You now have 2 great options to choose from!
Choose the option that fits you best and register below

Boot Camp Fitness Jumpstart - 4 week program
Only $299 per camp

Monday through Friday

This program is for someone who's ready to jumpstart their fitness program and get some serious mind-blowing results!

We recommend you attend 5-days per week to experience the greatest results. A minimum of 3-days per week is recommended to maintain your current fitness level and weight.

Adventure Boot Camp Inner Circle Membership
Only $225/per camp(Save 25% per camp!)
12 month program

Monday through Friday

We have a confession to make. North Pinellas & Westchase Adventure Boot Camp for Women is addictive. This program has quickly becoming our most popular. Campers tell us they are addicted to boot camp and many of them refer to themselves as "lifers". We know we've got a secret ingredient - fun, thrilling workouts that leave you begging for more. Every day at camp is different as we take you on a fitness adventure so you'll never have a ho-hum moment!

It's perfect for ladies who are tired of "spinning their wheels" and getting no where with their fitness program. If you want to reclaim your attractive, energetic body once and for all...this is for you!

Imagine how you will feel when you finally flatten your tummy, sculpt your butt, tone your thighs and fit into your skinny jeans! You can do this. I believe you simply cannot lose as long as you are committed and take action.

Inner Circle Early Cancellation Policy: I understand that I will be charged a $225 fee to my debit or credit card immediately if my 12 month contract is cancelled early.

Inner Circle Auto-Renew Policy: This program is a 12-month commitment which will renew automatically from camp-to-camp after the initial 12 month commitment is complete. After the 12 month commitment is complete, you may cancel anytime by phone or email; however notification should be receive by us no later than 30 days before the next camp starts.

Registration Form

Personal Information
Name		Address
City		State / ZIP	/
Profession		Country
Date of Birth	(mm/dd/yyyy)	Phone Number
Work Number		Mobile Number
Email Address

Self Assessment & Additional Information
I rate my current fitness level as a (1-10), ten being high.
I was referred by -- Please use full name:
How did you hear about us?:
This is my first camp:
If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number	\|

Camp and Payment Information
What camp are you joining? Please check camp calendar for availability
What time are you attending? Please check camp calendar for availability
Choose your camp frequency and cost. Please check camp calendar for availability. Inner Circle Early Cancellation Policy: I understand that I will be charged a $225 fee to my debit or credit card immediately if my 12 month contract is cancelled early. Inner Circle Auto-Renew Policy: This program is a 12-month commitment which will renew automatically from camp-to-camp after the initial 12 month commitment is complete. After the 12 month commitment is complete, you may cancel anytime by phone or email; however, notification should be receive by us no later than 30 days before the next camp starts.
If you have a Special Promotional Code, please enter it here. Your code will automatically provide you with the discount and/or promotional offer. Please note: Your discount will be reflected on your credit card statement, even though it will not be reflected on this page, it WILL be reflected on your credit card statement. You will not be charged the full price.
Form of payment: Please note: We no longer accept checks for payment. You must enter a credit card number below to receive a confirmation email and to reserve your spot. Please note: if you are using a "Gift Certificate" for payment, please enter the gift certificate code in the box above. We will contact you if there is a balance after applying your gift certificate.
Please note: The "Express" Camp option is only available when specifically offered on the Calendar page.

Credit Card Information
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. PLEASE verify all credit card numbers are entered before sending.
*Credit Card Number (No Spaces):*
Expiration Date:	/
Name on Credit Card:
*CVC Code:**	* (security code)
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. American Express On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code.

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

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 John Kent Fitness, Inc. d/b/a North Pinellas & Westchase Adventure Boot Camp for Women, its officers, subsidiaries, affiliates, and executors in addition to the City of Tarpon Springs, Pinellas County, City of Tampa, Hillsborough County and/or Life Path Christian Center. The purpose of North Pinellas & Westchase Adventure Boot Camp for Women 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 John Kent, nor the instructors of John Kent Fitness, Inc., 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 North Pinellas & Westchase Adventure Boot Camp for Women does not guarantee neither good nor bad will occur nor guarantees the training advice given by North Pinellas & Westchase Adventure Boot Camp for Women 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 North Pinellas & Westchase Adventure Boot Camp for Women 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 North Pinellas & Westchase Adventure Boot Camp for Women including John Kent 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 North Pinellas & Westchase Adventure Boot Camp for Women and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of North Pinellas & Westchase Adventure Boot Camp for Women. The undersigned agrees to a non-compete within a 50 mile radius of Tarpon Springs, Florida for a period of 5 years from date of participation.
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 to 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 and I give my permission for their use.
	I understand the following refund/makeup policy: 4-Week Jumpstart Refund Policy: If you are unable to attend camp due to circumstances out of your control, we can offer you a refund if you notify us prior to your session start date however we will charge a $50.00 cancellation fee. If we are notified after your session begins, we can only give you a credit to be used towards another boot camp. This credit is nontransferable. There is no cash refund. This is not negotiable. Inner Circle Early Cancellation Policy: I understand that I will be charged a $225 fee to my debit or credit card immediately if my 12 month contract is cancelled early. Makeup Policy: We do NOT offer make-up days. You must commit to the program for which you have signed up; and in order to get results, you need to be consistent in your workouts. We recommend you attend 5-days per week to experience the greatest results. A minimum of 3-days per week is recommended to maintain your current fitness level and weight.
	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.

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)

John Kent Fitness, Inc.
d/b/a North Pinellas & Westchase Adventure Boot Camp for Women
3377 Covered Bridge Dr. W.
Dunedin, FL 34698
John@BootCampRocks.com
Phone: (727) 420-8139

For More Information, Contact us at (727) 420-8139 or e-mail John@JohnKentFitness.com