B.U.S.Y. Body Boot Camp™ Fitness Questionaire
(All Fields Below in RED are required)
First Name: Last Name:
Age: Height: ft.in. Weight: lb.
1) Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2) Do you take any prescribed medication on a permanent or semi-permanent basis?
3) Do you have a seizure disorder (epilepsy)?
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)?
7) Do you have or have you ever had the following diseases?
| a) Heart Disease:|| || c) Kidney Disease:|| |
| b) Lung Disease:|| || d) Liver Disease:|| |
8) Do you have asthma?
9) Have you ever had a severe neck injury?
10) Have you ever been knocked out?
11) Do you wear glasses or contact lenses?
12) Have you had a broken bone or fracture in the past 2 years?
13) Have you ever injured your back?
14) Do you have back pain?
15) Have you had knee pain in the past 2 years that has disabled you for longer than
16) Do you have other physical conditions which cause pain?
17) Detail any surgical procedures youíve had (or enter "None"):
1) What are your goals for the next three months?
2) Have you had your body fat tested?
If yes, what percent is it? %
3) Are you training for a specific event?
If yes, explain:
4) What do you rate your current fitness level as?
5) Is this your first camp?
If you answered "no", when was the last camp you attended? (mm/dd/yyyy)
6) What is your MAIN goal? (be specific)
7) How did you hear about us?
Your Contact Information:
This release is entered into between the undersigned and B.U.S.Y. Body Fitness, LLC, its officers, subsidiaries, affiliates, and executors in addition to the City of Chattanooga. The purpose of The B.U.S.Y. Body 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:
- Acknowledges that Tonya Ransom 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 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.
- Acknowledges that boot camps, aerobic classes, kick boxing, running, 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 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 The B.U.S.Y. Body Boot Campô including Tonya Ransom, 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.
Customer client agrees to confidentiality with respect to The B.U.S.Y. Body Boot Campô and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of The B.U.S.Y. Body Boot Campô. The undersigned agrees to a non-compete within a 50 mile radius of Scenic City for a period of 5 years from date of participation.
I agree to all Terms and Conditions listed above.
Electronic Signature: (Enter your full name)
Make sure you fill out each applicable question completely
By checking this box, I agree to the conditions of
the B.U.S.Y. Body Boot Camp™ 1-Week & 4-Week Guarantees
Yes, I Agree