Booby Camp Registration

DIRECTIONS: Complete your registration using this online form. After you have registered, you will be given the opportunity to make your donation using PayPal or directly at Komen San Diego.

If you would prefer to pay using check or money order, please print out the registration confirmation e-mail you will receive, and mail it to the provided address.

PayPal and check or money order are the only payment methods we use, for our attendees' security.

Please fill in this form COMPLETELY. If there is a field that does not apply to you, please fill in N/A.

You will be e-mailed a copy of your registration; please print this for your records, and remember to bring a copy of your donation receipt to redeem for your FREE Booby Camp T-Shirt!

Fields that are mandatory are marked with a *.

Section I: Contact Information

Your Full Name: *

Postal Address: *

City: *

ZIP Code: *

Date of Birth: *

E-mail Address: *

Home Telephone Number: *

Work Telephone Number:

Fax Number:

Section II: Emergency Contacts

Primary Emergency Contact: *

Primary Emergency Phone Number: *

Secondary Emergency Contact:

Secondary Emergency Phone Number:

Section III: Medical History

IMPORTANT! Please complete this portion of the form completely. Booby Camp and Dave DePew Boot Camps shall not be held responsible in the event of medical complications arising from having incompletely or inaccurately completed the medical disclosures portion of this form!

All attendees should seek medical advice before beginning any health, fitness, or nutrition program!


Allergies
Are you allergic to any medication? *
(Aspirin, penicillin, sulfa, etc.)


Medications
Do you take any prescribed medication on a permanent or semi-permanent basis? *


Epilepsy
Do you have a seizure disorder and/or epilepsy? *
Yes: No:

Diabetes
Do you have diabetes? *
Yes: No:
If yes, please list your diabetes medications:


Anemia
Have you ever been found to be anemic? (Low blood count) *
Yes: No:

High Blood Pressure/Hypertension
Do you have High Blood Pressure? (hypertension) *
Yes: No:
If yes, please enter your hypertension medications:


Diseases
Do you have, or have you ever had, the following diseases?
Heart Disease: * Yes No
Lung Disease: * Yes No
Liver Disease: * Yes No
Kidney Disease: * Yes No

Do you have asthma? * Yes: No:

Have you ever had a severe neck injury? If so, please describe:


Have you ever been knocked out or had a concussion? If so, please describe:


Do you wear prescription contact lenses or eyeglasses? Yes: No:

Have you had a broken bone or fractured bone within the last two years? If so, please describe:


Have you ever injured your back? If so, please describe:


Do you have back pain?
Never:
Seldom:
Occaisionally:
Frequently with vigorous exercise or heavy lifting:

Have you had knee problems in the past 2 years that disabled you for longer than a week? If so, please describe:


Please detail any surgical procedures you've had:


Do you have any other physical conditions which cause pain, or other medical concerns about which we should be aware? If so, please describe:


Section IV: Release, Legal, & Disclaimers

This release is entered into between the undersigned and Dave DePew Boot Camps (division of Dave DePew Enterprises, Inc.) its officers, trainers, affiliates, trainers and executors in addition to the City of San Diego, and all other private and public locations for Dave DePew Boot Camps and the county of San Diego. The purpose of Dave DePew Boot Camps 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 no boot camp instructor is 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 Dave DePew Boot Camps does not guarantee neither good nor bad will occur nor guarantees the training advice given by Dave DePew Boot Camps 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. Videography and photography may be taken at various camp locations which may appear on TV, web video, print or any other digital format. When possible, the camp participants will be told in advance of the days in which any photography or videography will be done. "Before & after" photos will not be used for any promotional purposes unless written authorization is granted.

5. 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 ones 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 inherent dangers of the natural elements, 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 and Dave DePew Boot Camps for the undersigned participating in said sporting events and/or training for said sporting events.

6.) Booby Camp, Dave DePew Boot Camps, and/or Dave DePew, Inc. are not responsible or liable for boot camp instruction time that is not used due to any action or inaction on the behalf of the attendee, nor for any disruption of the boot camp arising from events beyond the control of Boot Camp Management, including emergencies and/or acts of God. Attendee acknowledges and warrants that any refunds for Boot Camp attendance or inattendance will be at the sole discretion of Boot Camp Management.

The Undersigned agrees and warrants that this is the full agreement between the parties, that Dave DePew Boot Camps, nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement freely and voluntarily without force or coercion.


BY SUBMITTING THIS FORM, YOU AGREE TO ALL OF THE ABOVE TERMS, CONDITIONS, POLICIES, AND PROCEDURES OF THE BOOBY CAMP, DAVE DEPEW BOOT CAMPS, AND DAVE DEPEW ENTERPRISES, INC. YOU FURTHER WARRANT THAT YOU FULLY UNDERSTAND ALL OF THESE TERMS AND CONDITIONS, AND THAT YOU HAVE COMPLETED THE MEDICAL DISCLOSURES PORTION OF THE REGISTRATION FORM TO THE FULLEST POSSIBLE EXTENT.

YOUR IP ADDRESS WILL BE RECORDED AS PART OF YOUR SUBMISSION.

Please enter your full name and last four digits of your Social Security # to serve as your legally-binding digital signature:
Type your full name here:

Enter the LAST FOUR DIGITS ONLY of your SSN here:

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We look forward to seeing everyone at Booby Camp!

  

Booby Camp is a Public Service Project of Dave DePew Enterprises, Inc and Dave DePew Boot Camps.