EZ8 Running Camp - Running - Rosa Hurst & Sherry Shelton, Instructor
EZ8 Running Camp - Running
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EZ8 Runners Registration Form & Release

Thank you for registering for the EZ8 & Endurance Runners Program. Please complete and submit the form below. Once we have received your completed registration form and payment, we will send you a confirmation by email with additional information. (You may also purchase an EZ8 Running Program gift certificate for someone else.)

EZ8 Running Program Registration Form
Full name:
Address:
City:
Zip:
Profession:
Date of birth:
Home phone:
Cell phone:
Work phone:
Fax number:
E-mail address:
Camp Date:
 BEG = Beginner   INT = Intermediate 
Camp Level :
Beginner Intermediate
Type of Camp:
4 WEEK CAMPS:
Beginner
Intermediate
This is my first EZ8 Running Program:
Yes
No, last program attended (Month - Location):
Emergency contact:    Phone:
I rate my current
fitness level as a:		 (1-10), 10 being high
I was referred by:
How did you find us?
(Please be specific. Thanks!)
My main goal is to:
My minute mile is: (Date ran)
Comments:

MEDICAL HISTORY

If you are returning and have no medical changes, the medical section below does not need to be completed. All agreements remain the same. NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

What is the date of your last physical exam?
     
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)? Yes No
4. Do you have diabetes adult or juvenile? Yes No
     List medications:
5. Have you ever been found to be anemic (low blood count)? Yes No
6. Do you have high blood pressure (hypertension)? Yes No
     List medications:
7. Do you have or have you ever had 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
      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? Yes No
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? Never    Seldom    Occasionally    Frequently with vigorous exercise or heavy lifting
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? Yes No
     If yes, what percent is it?
20. Are you training for a specific event?  
21. What do you think your timed mile will be?  
22. How much have you been running lately?  

RELEASE

This release is entered into between the undersigned and North Atlanta EZ8 Running Camp/Iron Ballet LLC. The purpose of the EZ8 Running Camp/Iron Ballet LLC is to provide running 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 Sherry Shelton 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 EZ8 Running Camp/Iron Ballet LLC does not guarantee neither good nor bad will occur nor guarantees the training advice given by the EZ8 Running Camp/Iron Ballet LLC 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 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 the EZ8 Running Camp/Iron Ballet LLC 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 EZ8 Running Camp/Iron Ballet LLC, 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.

Check the following:

I agree that I will not consume alcohol during the month of the Running Camp. Any violation will result in a 1 mile run per occurrence.
I agree not to use foul language during the EZ8 Running Camp. Any violation will result in a 1 mile run per occurrence.
I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of the EZ8 Running Camp. Any violation will result in a 1 mile run per occurrence.
I agree to show up for my runs every day unless it is an excused absence from my doctor or pre-approved with the running directors. Any violation will result in a 1 mile run per occurrence.
I understand that photos or video may be taken during the course of my involvement in the Running 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 the program) towards a future running camp if I'm not able to complete the one I originally joined (due to injury or major illness). We also have an alignment with North Atlanta Boot Camp, and that credit may also be applied to one of their fitness boot camps.
I will remember to set my alarm and be at camp on time.

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

PAYMENT

Your registration will be confirmed only after receipt of payment. Space is limited, so please submit your payment immediately.  Payment must be received PRIOR to the 1st day of camp.
    Please select your payment method:
Paying online with credit card.
Mailing check.

By submitting this form, you are agreeing to the terms above!

Homepage | About the Program | FAQs | Schedule | Registration | About Us | Contact Us
North Atlanta Running for Women www.NorthAtlantaRunning.com Atlanta, Georgia
For more information call 404-978-5362 or write to info@bellanafitness.com