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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)? List Medications:
4	Do you have diabetes Adult or Juvenile?
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 Heart Disease?
8	Do you have or have you ever had Lung Disease?
9	Do you have or have you ever had Kidney Disease?
10	Do you have or have you ever had Liver Disease?
11	Do you have asthma? List Medications:
12	Have you ever had a severe neck injury?
13	Have you ever been knocked out?
14	Do you wear glasses or contact lenses?
15	Have you had a broken bone or fracture in the past 2 years?
16	Have you ever injured your back?
17	Do you have back pain?
18	Have you had knee pain in the past 2 years that has disabled you for longer than a week?
19	Do you have any other conditions which will limit your participation in boot camp?
20	Detail any surgical procedures:

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

LIABILITY RELEASE
This release is entered into between the undersigned and Eastern Mass Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Eastern Mass. The purpose of Eastern Mass Adventure 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 agreed upon.

Checkmark the following:

1. Acknowledges that Eastern MA Bootcamp instructor is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Eastern MA Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Eastern MA Boot Camp instructor including Eastern MA Adventure Boot Camp will produce good nor bad results. 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 their training or otherwise, that the undersigned should contact a physician at once.

2. 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 Eastern Mass Adventure Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.

3. I understand that Eastern MA Adventure Boot Camp has the right to terminate any participant for any reason with one week's notice. This includes but is not limited to: non-participation, excessive tardiness, disruptive verbal or physical conduct, or non-payment.

The Undersigned agrees that this is the full agreement between the parties, that Eastern Mass Adventure Boot Camp including Eastern Mass Bootcamp Instructor 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.

The undersigned, in consideration of my participation in the Eastern mass Adventure Boot Camp and the services provided to me in connection with my participation therein, recognize that the company's business and its practices are special and unique and that access to and knowledge of which are essential to my involvement with its programs. I agree not disclose any such information to any person, firm corporation, association or other entity for any reason or purpose whatsoever or make use of any such property for my own purposes or for the benefit of any person, firm, corporation, association or other entity and hold such information as being confidential. I further agree that I shall not, for a period of five (5) years from the date of my last participation, directly or indirectly, establish or engage in any business which competes with Eastern Mass Adventure Boot Camp.

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