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Falmouth Boot Camp Registration
Maine Boot Camp Class
REGISTRATION FOR 2010 WINTER CAMPS IS NOW OPEN

YOU ARE 2 STEPS AWAY FROM COMPLETING YOUR REGISTRATION FOR MAINE BOOT CAMP

1. Complete the Maine Boot Camp information form below that includes your personal, fitness, and medical background

2a. Register and pay on-line by clicking on the the REGISTER ON-LINE button which will take you to the Town of Falmouth's Activenet site where you will create a User Account, register for the program and complete the payment process.
*A transaction fee is charged by the Town of Falmouth when registering on-line.

OR

2b. Print and complete the Town of Falmouth Parks and Recreation Registration Form by clicking on PRINT REGISTRATION FORM. The completed form with payment may be dropped off at the Falmouth Town Hall or mailed to: FCP, 271 Falmouth Road, Falmouth, Maine 04105-2005. All checks should be made out to: TOWN OF FALMOUTH.

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

Registration Form
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?:
This is my first camp: Yes | No
If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number |
Camp Information
(The 3 and 4 day-per-week options are for those campers have other commitments in the early a.m. Since it is only a 4-week class, we do prefer you attend the full 5-day a week program for best results and overall work-out! You can do it!)
What camp are you joining?
Choose your camp frequency and cost.
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: s
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 Maine Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the Town of Falmouth. The purpose of Maine Boot Camp 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 Casey Ericson 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 Maine Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Casey Ericson including Maine 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 Maine Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.

5. Falmouth Community Services Registration Waiver I understand the risks associated with participation in the above listed activity. I hereby agree to release discharge, indemnify and hold the Falmouth School Dept. and Falmouth Community Services and their agents and employees harmless from any liability claims, demand costs or damages arising out of said program activity which I might sustain during participation. I have read this document carefully and sign it voluntarily with full knowledge of its significance.

The Undersigned agrees that this is the full agreement between the parties, that Maine Boot Camp including Casey Ericson 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 Maine Boot Camp and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of Maine Boot Camp.  The undersigned agrees to a non-compete within a 50 mile radius of Maine 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. 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 joined. Camp fees can not be used towards any other products or services provided by Maine 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
Agreement and Signature
I agree to all Terms and Conditions listed above
Electronic Signature
Date (MM/DD/YYYY)
**You will received your pre-camp information the week prior to the start of camp. You will also be contacted to schedule your pre-camp evaluation (if needed for your program) at this time. Pre-camp evaluations usually take place at the end of the week prior to the start of camp.

 
For More Information, Contact us at (207) 992-6161 or e-mail info@mainebootcamp.com
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