Registration

Fit and Fun Adventure Boot Camp

Phone: (301) 343-4294 or (240) 475-1452
email: info@mirrorimagefitness.com

To register for a boot camp, or to register for a group fitness class, please submit your information using the form below. An invoice will be emailed to you. Checks, Cash, and Major Credit Cards are accepted. Please note that boot camp classes and yoga classes are available for a drop in cost of $18. Other group fitness classes are available at a drop in cost of $12.

If you would like to pay by credit card, please complete and submit the form below.
Credit cards are processed using Pay Pal.

Another option is to print the form here, and fax it to 301-649-1064.
(note, you will need Adobe Reader to view and print this form)

* required

    * First Name:
    * Last Name:
* Address:
Address2:
* City:
* State: (ie MD)
* Zip:
Profession
Date of Birth           
Emergency Contact:
Emergency Phone:
* Email Address:
* Phone:

Fitness Level: 1(low) to 10 (high)

Referred By:

How Did You Find Us?  

My Main Goal Is:  


* I Want to Register For: 


* Camp: 


* Class: 
* Session Option: 
* Session Option: 
 

Medical History
(If You are a returning camper please only complete the answers that have changed)

   
1. List any medication allergies (Aspirin, Penicillin, Sulfa, etc.):

2. List any medications that  you are taking on a permanent or semi-permanent basis:

3. Do you have a seizure disorder? (epilepsy)
    Yes No
4. Do you have adult or juvenile diabetes
    Yes No
5. Have you ever been found to be anemic? (low blood count)
    Yes  No
6. Do you have high blood pressure? (hypertension)
    Yes No
7. Do you have or have you ever had any of the following diseases?  
   Heart Disease     Yes   No

   Lung Disease      Yes   No

   Kidney Disease   Yes   No

   Liver Disease       Yes   No

 
8. Do you have asthma
    Yes No
9. Have you ever had a severe neck injury? Yes No

If yes please describe

10. Have you ever been knocked out? Yes No

If yes please describe

11. Have you ever had a broken bone or fracture in the last two years? Yes No

If yes please describe

12. Do you have back injury or pain?
  		Yes No
13. Have you had knee pain within the last two years that has disabled you for longer than a week? Yes No
14. Please list any other physical conditions which cause pain.
15. Please detail any surgical procedures
16. What are your goals for the next three months?

17. If you have recently had your body fat tested, please list the percentage
18. Are you training for a specific event (5k, marathon, etc.)? If yes, please describe:

NOTICE: It Is Wise To Seek Your Doctors Advice Before Beginning Any Health/Fitness/Nutrition Program

Consent for Exercise

This agreement is entered into between the undersigned and Mirror Image Fitness LLC, its officers, subsidiaries, affiliates, and executors in addition to the City of Silver Spring and Montgomery County .   The purpose of Mirror Image Fitness is to provide fitness instruction and coaching for various levels of athletes/individuals.

The undersigned hereby acknowledges that the following was explained to me and/or agrees to the following:

1.        I Acknowledge that Mirror Image Fitness is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.

2.        I Acknowledge that Mirror Image Fitness exercise programs are designed to gradually increase work load on the cardio-respiratory and musculoskeletal systems in order to effect improvements. The bodys reaction to gradually increasing exercise activities cannot be predicted with complete accuracy. Unusual changes during or following an exercise session may occur. These may include muscular or joint injury, abnormal blood pressure, fainting, disorders of heart beat, and/or very rare instances of heart attack or death.

3.        I Acknowledge that the undersigned has been advised if they feel tired, feel pain, or feel out of the ordinary in any way (whether related to training or otherwise), that the undersigned should contact a physician.

4.        I acknowledge that I have read the foregoing and I understand the objectives, procedures, potential risks and benefits involved in this exercise program.   Unless otherwise indicated, I certify that I am in good health and have no condition that would prohibit/limit my participation in a structured exercise program.   I understand that if there are any questions about the procedures or methods used during an exercise session, I should ask my coaches. I realize that injury may result from improper exercise techniques or misuse of exercise equipment. I agree to be attentive to all instructions given to me and to exercise and use equipment correctly. I assume responsibility for monitoring my own condition throughout the exercise program and should any unusual symptoms occur, I will inform my coaches. I shall also notify my coaches of any changes in my medical status.   I consent to the administration of any immediate resuscitation measures deemed advisable by my coaches.

5.        I Acknowledge that Mirror Image Fitness will provide the safest instruction for individuals to participate in various exercises at varying levels of difficulty, based on the attached medical history form

The undersigned agrees that this is the full agreement between the parties.   That Mirror Image Fitness nor anyone else has 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.

Signature

____________________________________

Printed Name

____________________________________

Date

____________________________________


 

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