Cardiff Workout by the Sea On-line Registration

Here are the 2 options for registration:
A. You can fill out and print this form and send it in with payment by mail or fax (760)944-7731, or
B. Fill out this online form to register, then press submit to send us the form you will then be re-directed to our payment page where you can pay for the classes.

First Name:

Last Name:

E-Mail:

Mailing Address:

City:

State:

Zip:

Physical address if different from above

Profession:

Date of Birth:

Phone number:

Work Phone:

Mobile:

I rate my current fitness level as (1-10), 10 being high 1 2 3 4 5 6 7 8 9 10

My main goal is:

Emergency Contact:

Contact Phone:

Which time are you signing up for?
5:30-6:30 AM
6:30-7:30 PM

Which program are you signing up for?
Camp 1 Camp 2 Camp 3 Camp 4 Camp 5 Camp 6 Camp 7 Camp 8 Camp 9 Camp 10

$299.00 - 5 days a week for 4 weeks
$199.00 - 3 days a week for 4 weeks
$225.00 - 5 days a week for 3 weeks (holiday express camp only)

Note: If paying by check, please print this on-line form and e-mail or fax it in with payment.

* Please note - we cannot guarantee your reserved spot until payment is received.

Medical History (If you are a returning camper, only complete the sections that have changed)

1. Are you allergic to any medications (aspirin, penicillin, sulfa, etc.)? Yes No

2. Do you take any prescribed medication on a permanent of semi-permanent basis? Yes No

List Medications:

3. Do you have a seizure disorder (epilepsy)? Yes No

4. Do you have diabetes? Yes No

5. Have you ever been found to be anemic (low blood pressure)? Yes No

6. Do you have high blood pressure? Yes No

7. Do you have or have you ever had the following diseases?
Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:

8. Do you have asthma? Yes No

9. Have you ever had a severe neck injury? Yes No

10. Have you ever been knocked out?
Describe

11. Do you wear glasses or contact lenses? Yes No

12. Have you had a broken bone or fracture in the past 2 years?
Explain

13. Have you ever injured your back? Yes No

14. Do you have back pain? Yes No

15. Have you had knee pain in the past 2 years that has disabled you for longer than a week? Yes No

16. Do you have other physical conditions which cause pain?
Explain

17. Detail any surgical procedures

18. Have you had your body fat tested? Yes No
If yes, what is your percent?

19. Are you training for a specific event?
If yes explain

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

RELEASE: This release is entered into between the undersigned and Cardiff Workout by the Sea. The purpose of Cardiff Workout by the Sea 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 your trainer, Alisha Ramirez, 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 Cardiff- Workout by the Sea does not guarantee neither good nor bad will occur nor guarantees the training advice given by Cardiff-Workout by the Sea 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 women’s outdoor fitness 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 Cardiff- Workout by the Sea for the undersigned participating in said sporting events and/or training for said sporting events.

The Undersigned agrees that this is the full agreement between the parties, that Cardiff- Workout by the Sea 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.

Initial the following:

I understand that photos or video may be taken during the course of my involvement in 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 Camp fees cannot be used towards any other products or services provided by Cardiff- Workout by the Sea.

I will remember to set my alarm and be at camp on time.

I agree to show up for Camp every day unless it is an excused absence from my doctor or pre-approved with Boot Camp directors. Any violation will result in added workouts.

I UNDERSTAND THAT I AM SIGNING UP FOR 4 WEEKS - NO EXCUSES! If you have a pre-planned trip and know you will miss a couple days of camp, you MUST let your instructor know before you sign up in order to receive up to 2 days credit towards a future camp. We cannot credit towards injuries occurring out of camp.

All camp information, training and information are considered exclusive information of Cardiff- Workout by the Sea.A workout by the Sea, Inc. retains the right to full exclusivity. You agree not to copy, imitate nor attempt to reproduce the training regime provided to you within a 45 mile radius.

By signing and or SUBMITTING, you agree to all of the terms above and acknowledge that you filled out this form with complete honesty.

Signature Date

Printed Name