Space Coast Adventure Boot Camp
Boot Camp Registration & Release Form

You have 2 options for registering:

  1. Fill out the form below (there are 2 Steps) to register and pay securely through Paypal using a credit card.
  2. You can contact us to receive a registration form in the mail and send your payment by mail.

NOTE: We cannot guarantee your space will be reserved if you do not supply us with payment information on this form if sending via internet.

If paying by check, please make check* out to:
Space Coast Adventure Boot Camp or SCABC
3147 Arden Cir.
Melbourne, FL 32934
Diane@SpaceCoastBootCamp.com
Tel: (321) 749-8361
Fax: (321) 253-4906

If you choose option 1, please fill out the form below and click Submit . . . I am ready to get fit!

Camp
Location
(click for map)
Time & Details
A
Gleason Park, I.H.B.
5:45 - 6:45 am
(Note: 3 days per week MWF)
B

8:30 - 9:30 am
M-F
C

5:45 - 6:45 pm
(Note: 3 days per week MTTh)

Per month pricing (your credit card will be billed monthly for packages):

Package

Basic Membership

(3 days/wk)

Intermediate membership

(4 days/wk)

Full Membership

(5 days/wk)

One Month Commitment

$120 / month
$160 / month
$200 / month

Want to try Boot Camp out??

NEW!! Trial Membership - ONLY $39 - 3 classes in one week!!

Regsiter below for all memberships.

STEP 1: Complete Registration Form

You will be notified to schedule your pre-camp evaluation (if needed for your program).

Name *
Street Address
City
State
ZIP
Profession
Country
Date of Birth (mm/dd/yyyy)
Phone Number Work Number
Fax Number  
Email Address
I rate my current fitness level as a (1-10), ten being high.
I was referred by:
How did you hear about us?: Please specify publication / website / friend or other referral:
This is my first camp: Yes | No If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number
Camp Location



Which Package?

Full (Including Boot Camp 3 days per week)
(Not Including Boot Camp)




T-Shirt Size (Metabolic Transformation Only)



Form of payment:    
 
Note: If paying by check, please print this online form and mail or fax it in with payment.  To guarantee a spot today, please pay online on the page you will be taken to after you click the "submit" button below. The transaction is secure, and all you need is a credit card.
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 the following diseases?
Heart Disease:
  
Lung Disease:  
Kidney Disease:  
Liver Disease:  
8. Do you have asthma?
List Medications:  
9. Have you ever had a severe neck injury?
 
Describe:
10. Have you ever been knocked out?
 
Describe:
11. Do you wear glasses or contact lenses?
12. Have you had a broken bone or fracture in the past 2 years?  
Describe:
13. Have you ever injured your back?  
Describe:
14. Do you have back pain?
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
 
Describe:
16. Do you have other physical conditions which cause pain?  
Describe:
17. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat tested?
If yes, what percent is it?
20. Are you training for a specific event?
If yes, explain:

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

RELEASE
This release is entered into between the undersigned and Space Coast Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the City of Melbourne and Brevard County. The purpose of Space Coast 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 agree to the following:

1. Acknowledges that Diane Schullstrom and all boot camp instructors are not physicians and are 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 Space Coast Adventure Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Space Coast Adventure Boot Camp 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 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 Space Coast Adventure Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.

5. That any information obtained by Customer/Client while enrolled by programs provided by Space Coast Adventure Boot Camp regarding the nature of Owner’s business, services, fees programs, materials, commissions, customers, or any of its activities, is highly confidential, and is important to Owner, and to the effective operation of the Company’s business. Customer/Client therefore agrees that while enrolled by Space Coast Adventure Boot Camp and at any time after the enrollment, Customer/Client will make no disclosure of any kind, directly or indirectly, concerning any such confidential matters relating to the business of the Owner.

6. Participant agrees that Space Coast Adventure Boot Camp has a legitimate business interest in its valuable confidential business information, customer goodwill, the specialized training provided by Boot Camp to Participant, and that it’s operation is intended to result in an expanding network of existing and prospective clients and the establishment of goodwill, name recognition, and referrals within Brevard County, Florida. In recognition of these legitimate business interests, Participant agrees while participating in the services under this Agreement, and for a period of twenty-four(24) months thereafter, Participant shall not compete with Boot Camp in any way, including, but not limited to, providing services in Brevard County for another boot camp-type program (whether or not such program is described as a boot camp), forming or establishing a boot camp-type program in Brevard County (whether or not such organization is described as a boot camp), or utilizing SCABC’s valuable confidential business information in any other business, program or activity.

7. SCABC reserves the right to cancel camp class for instructor illness, rainout, and/or for any major holidays, i.e. New Year's Day, Memorial Day, July 4th, Thanksgiving, Christmas and any others to be determined. All efforts will be made to find a qualified substitute in the event of instructor illness.

8. SCABC will not offer make up days for less than one week of absence. Absence must be due to travel or extended illness or injury. Notice to SCABC must be provided in writing in advance of travel, or within first three days of illness to be given an extension of agreement.

The Undersigned agrees that this is the full agreement between the parties, that Space Coast Adventure Boot Camp 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.

Checkmark the following:
I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence.

I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence.

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

I understand that photos or video may be taken during the course of my involvement in Boot 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, but I can receive a credit (for unused portion of camp) towards a future camp if I'm not able to complete the one I originally joined, following the guidelines in #8 above. Camp fees can not be used towards any other products or services provided by Space Coast Boot Camp.

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

I understand that diet and nutrition will effect my fitness goals and performance during Boot Camp.

I will bring a positive attitude, and expect to have fun!

Your signature will be required at the time of your evaluation and you agree to the terms now!

____________________
Signature (only if printed and mailed)

____________________
Printed Name (only if printed and mailed)

____________________
Date (only if printed and mailed)
 
(Next: Step 2 - Payment)
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