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Mesa Boot Camp Registration Form

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Fields with * are required fields.

E-mail Address: *
Full Name: *
Address: *
City: *
Zip: *
Date of Birth: *
Emergency Contact & Phone *
Your Home Phone: *
Your Work Phone:
Fax:
Your Job Description? *
Program Type: *
Camp Start Date and Time: *
Is this your first camp? *Yes
No
If you answered no above, when was the last camp you attended?
How did you find out about Mesa Boot Camp?
I rate my current fitness level as a: *
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? If Yes, list medications:
5. Have you ever been found to be anemic (low blood count)?Yes
No
6. Do you have High Blood Pressure (hypertension)? (List medications if applicable:)
7. Do you have or have you ever had any of the following diseases: Heart Disease, Lung Disease, Liver Disease, Kidney Disease. (If yes to any please specify)
8. Do you have asthma? (List medications if applicable)
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?Yes
No
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?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? 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?
By clicking this checkbox I signify that I have read and agree with all of the above text. *
* Required

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For More Information, Contact us at (480) 201-7537 or e-mail Nicole@MesaBootCamp.com
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