CYBBC Registration

In consideration of me being permitted to participate in any way in the Change Your Body Boot Camps^SM sponsored Activities (“Activity”), I agree:

I understand the nature of Change Your Body Boot Camps^SM activities and believe I am qualified to participate in such Activity. I further acknowledge that I am aware the activity will be conducted in facilities open to the public during the Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.

I FULLY UNDERSTAND that: (a) Change Your Body Boot Camps^SM Activities involve risks and dangers of SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (“Risks”); (b) these Risks and dangers may be caused by my own actions, or inaction’s, the actions or inaction’s of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a result of my Participation in the Activity.

I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS Change Your Body Boot Camps ^SM , their respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes place (each considered one of the “Releasees” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the “Releasees” or otherwise, including negligent rescue operations and further agree that if, despite this release, I, or anyone on my behalf makes a claim against any of the Releasees named above, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE OR COSTS ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.

By signing below I GIVE PERMISSION to Change Your Body Boot Camps^SM , Athletes by Alves^SM and Mike Alves to USE MY IMAGE, VOICE AND LIKENESS IN VARIOUS MARKETING AND ADVERTISING MATERIALS AND PROMOTIONS not limited to brochures, business cards, flyers, websites, pamphlets, television, internet, signage, billboards, moving signs, mailings, print media and radio media. I am aware and understand that I may be videotaped, photographed and audio recorded during this activity and my personal images and auditory noises/words spoken are examples of what may be used.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND IT’S TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

Description of the Exercise Program and Potential Risks: I understand and do hereby consent to participate in a fitness training program that will include resistance training, plyometrics, stretching and/or cardiovascular exercises. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to occasional minor injuries (e.g. pulled muscles, muscle soreness, musculo-skeletal strains and sprain, bruises) to infrequent serious injury (e.g., heart attack, stroke or other cardiovascular accidents, muscle tears) to the very rare catastrophic incident (e.g., death, paralysis). I acknowledge that regardless of the care taken by my trainers that he or she cannot guarantee my personal safety.

Participant Responsibilities: I understand it is my responsibility to 1) fully disclose any health issues (including diabetes, heart problems, seizures, and asthma) or medications that are relevant to participation in a strenuous exercise program; 2) inform the trainer if there are changes to my health, including injuries and sickness 3) inform the trainer if there are activities with which I do not feel comfortable; 4) cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program; and 5) clear my participation with my physician.

Participant Acknowledgments: In agreeing to this exercise program, I, the participant 1) acknowledge that my participation is completely voluntary; 2) understand the potential physical risks involved in the exercise program and believe that the potential benefits outweigh those risks; 3) give consent to certain physical touching that may be necessary to ensure proper technique and body alignment; 4) understand that the achievement of health or fitness goals cannot be guaranteed; 5) have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction; 6) am in good physical condition, have no impairment which might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program; 7) have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop.

I have read and understand the above agreement. I have been made fully aware of and understand the potential risks involved in this physical fitness program. I hereby consent to those risks and am freely and voluntarily participating in the program. Finally, I am freely signing this agreement.

Personal Info
First Name:	Last Name:
Address:
City:	State: Zip Code:
Phone: (Home)	(Work) (Cell)
Email :	Referred by:
Date of Birth:	Age: Are you a mother or father?
Occupation:	Employer:
Gender:	Height:Ft Inches Weight: lbs
Emergency Contact:	Relation to you: Phone:
Physician Contact Info
Name:
Address:
City:	State: Zip Code:
Phone:
Which Class Time:	# of Days / Week: Which Days:

* Your personal information will not be shared or sold to 3^rd parties. It is requested to understand you better, to thank you for applying and to contact you as needed.
Registration Questions:
1. Have you ever signed up for a boot camp before, Yes/No?	Yes No
2. If yes, what was the name, where was it located and why did you stop?
3. What made you decide to sign up for Change Your Body Boot Camps?
4. What do you hope to accomplish?
5. How can I help you with this?
6. Boot camps are group classes. Think of it as a team or a family. Yes/No. Will you support and encourage your new teammates?
7. Will you commit 100% to attending all classes/functions, follow your nutrition plan and complete your cardio program as prescribed to you?

Regular physical activity is fun and healthy, and being more active is very safe for most people. If you answer YES to any of the following questions, talk to your physician about the implications of becoming more physically active by participating in Change Your Body Boot Camps^SM programs.
1. Are you a man over the age of 45 or a woman over the age of 55? Yes No
2. Do you have a heart condition? Yes No
3. Do you ever feel pains in your chest? Yes No
4. Do you easily lose your balance; get dizzy or lose consciousness while either sedentary or active? Yes No
5. Do you have a bone, muscle or joint problem that could be made worse by becoming more physically active? Yes No
6. Are you currently taking drugs for blood pressure, cholesterol, diabetes, or heart conditions? Yes No
7. Are cardiovascular risks (diabetes, heart disease, high blood pressure or cholesterol) present in your immediate family? Yes No
8. If you are female, are you currently pregnant or have you recently given birth? Yes No
9. Do you have chronic pain? Yes No
10. Are you currently sedentary? Yes No
11. Are there any other issues, concerns, or special circumstances that may increase the risk of injury or harm to you, other participants or Trainers as a result of your participation in the Change Your Body Boot Camps^SM programs? Yes No
I have read and answered NO to all of the above questions or answered YES to one or more questions and have cleared my participation with my physician.