Boot Camp Registration Form
Please Complete Form. After Submitting...You can pay by mailing check payable to JUST IN SHAPE at 1911 Creek Stone Dr Opelika, AL 36804 or via Credit by clicking PAY NOW logo Riverside, AL www.justinshape.com/24.html Auburn, AL www.justinshape.com/28.html
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First Name:
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Last Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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Email:
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Emergency Contact:
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Relationship:
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Phone:
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Sex:
M
F
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Date of Birth:
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History of Heart Problems:
Yes
No
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High Blood Pressure:
Yes
No
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Diabetes:
Yes
No
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High Cholesterol:
Yes
No
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Surgery in the Last 5 Years:
Yes
No
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Pregnancy in the Last Year:
Yes
No
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Breathing Problems:
Yes
No
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Smoking Habit:
Yes
No
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Joint Problems:
Yes
No
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Any Other Chronic Illness or Condition:
Yes
No
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Advice from Physician NOT to Exercise:
Yes
No
Explain:
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Camp Date:
July 7 thru Aug 1
TBA
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Camp Time:
6:30am - 7:30am
TBA
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ELECTRONIC SIGNATURE:
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Date:
Please click on the Submit button to submit the form details.
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