Please take a few minutes and answer these questions.  It is very important that you approach your training in a safe manner.   Once you have submitted these, I will email you a confirmation, and give you more details about your class.  Thanks, Stephen

Name *
Name
Address *
Address
Phone
Phone
Which class do you prefer? *
I prefer that you choose one class, but if your schedule does not allow for this, please contact me, and we will work out something for you.
Medical Information
Has your doctor ever said that you have a heart condition and that you should only perform physical training under the care of a doctor?
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Has a physician ever diagnosed you as having high blood pressure? (>160/90) *
Are you on blood pressure medication? *
Regarding your cholesterol. Is the value >240 mg/dl? *
Do you smoke? *
Do you suffer from diabetes? *
Has anyone in your immediate family suffered coronary or atherosclerotic disease before age 55? *
Ladies, are you or do you think you might be pregnant? *
If none, just say none.
If so, to what?
Goals
Please give me as much information as you think will help me in personalizing your program.
The exercise sessions you will become involved with and undertake will consist of progressive exercise levels and be determined and regulated by your trainer. The exercise sessions will consist of aerobic and weight training as well as education and instruction. These exercises are designed to place a gradual increasing stress on the body and as such to improve the body’s function, although no guarantee can be made. I am aware that all activities are offered as recreational or self directed in nature and I have the right and choice to stop activity at any time. I also assume full responsibility during and after my participation for any risk, discomfort or fatigue that I may experience. I understand that exercise and cardiovascular activity and the response of my body to such activity cannot be predicted. I acknowledge my responsibility and obligation to inform the nearest supervising employee of any pain, discomfort, fatigue or any other symptoms that I may suffer and that it is my choice to participate in the training program. I also understand that my trainer or other staff may not be licensed, certified, or registered instructor and that skill levels may vary and that I accept assumption of all the risk that may imply as my own. The information made and obtained during the training sessions is treated as confidential. However it may be used for statistical purpose as long as my privacy is not compromised. I understand that I may ask any questions or request further information about any of the activities, programs, or services offered at any time before, during or after participation. I may take as long as I need to think the program over and can participate now or withdraw at any time. I have read the above and consent to participate in a fitness program.
I grant to Stephen Cooper and Boot Camp Pasadena, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Stephen Cooper and Boot Camp Pasadena , its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Stephen Cooper and Boot Camp Pasadena may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.