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Registration
Last Name:
First Name:
Middle Initial:
Address:
City:
State:
Zip:
Home Phone:
Work Phone: Ext.
Fax Number:
Mobile/Pager:
Date of Birth: / / (MM/DD/YYY)
Body Weight:
Sex: Male Female
Private Physician:
Private Physician Phone:
Emergency Contact:
Emergency Contact Phone:
Your Company:
Email:
Referred by:

I , (FULL NAME) agree to participate in Athletic Combined Training Systems, LLC Boot Camp with a certified Athletic CTS instructor. I recognize that exercise is not without varying degrees of risk to the muscle skeletal and/or cardio respiratory system. I hereby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by Athletic Combined Training Systems, LLC.

I understand and have been informed that there exists the possibility of adverse changes during the exercise program. I have been informed that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and very rare instances of heart attack or even death.

I agree to waive, release, remise and discharge, Athletic Combined Training Systems, LLC, and its agents, officers, principals and employees of any and all claims, demands, actions or damages of any kind resulting from participation in Athletic Combined Training Systems training. The undersigned hereby releases Athletic Combined Training Systems, LLC as well as waives any and all claims and understands and assumes any and all risk with participation in Athletic Combined Training Systems Training.

SIGNATURE:_________________________________________

DATE:_______________________________________________

SECTION II: CARDIAC RISK ASSESSMENT

Have you ever had any form of heart disease?: Yes No
Have you ever experienced shortness of breath or chest pains? Yes No
Date of last full physical: / / (MM/DD/YYY)
Do you have or do any of the following pertain? Please explain to the best of your ability.
High Blood Pressure: Yes No
Levels:
High Cholesterol Level: Yes No
Levels:
Cigarette Smoking: Yes No
How many per day?
Smoked in the Past? Yes No
How long?
Diabetes? Yes No
Insulin Dependent?
Family History of Heart Disease: Yes No
Who? Age?
Abnormal Resting EKG? Yes No
Explain:
Are you active? Yes No

Activity or Exercise?

Times per Week:
Minutes per Session:

Do you have problems in the following areas?  
Knee: Yes No
Explain:
Low Back: Yes No
Explain:
Neck/Shoulder: Yes No
Explain:
Hip/Pelvis: Yes No
Explain:
Flexibility: Yes No
Explain:
Any Other: Yes No
Explain:
Are you currently taking any medication? Yes No
Explain:
 
 
 
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