Vital Steps Boot Camp Membership Sign-Up Form
If you are a NEW STEPPER, sign up to become a member of Boot Camp by filling out this Membership Registration Form.

*Required field

Name *
Address *
City *
Postal code *
Profession
Date of Birth (mm/dd/yy) *
Phone *
Work Number *
Fax Number
I rate my current fitness level as a (1-10), ten being high. *
I was referred by
How did you hear about us?
This is my first camp * Yes
No
If you answered "no", when was the last camp you attended
My main goal is... *
Name of Emergency Contact & Phone Number *
. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? * Yes
No

List medications
Do you have a seizure disorder (epilepsy)? * Yes
No
Do you have diabetes Adult or Juvenile? * Yes
No

List medications
Have you ever been found to be anemic (low blood count)? *
Do you have High Blood Pressure (hypertension)? * Yes
No

List medications
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
Do you have asthma? * Yes
No

List medications
Have you ever had a severe neck injury? Describe (Leave blank if NO). *
Have you ever been knocked out? Describe (Leave blank if NO). *
Do you wear glasses or contact lenses? * Yes
No
Have you had a broken bone or fracture in the past 2 years?Describe (Leave blank if NO). *
Have you ever injured your back? Describe (Leave blank if NO). *
Do you have back pain? *
Have you had knee pain in the past 2 years that has disabled you for longer than a week? Describe (Leave blank if NO). *
Do you have other physical conditions, which cause pain? Describe (Leave blank if NO). *
Detail any surgical procedures. (Leave blank if NO). *
What are your goals for the next three months? *
Have you had your body fat tested? * Yes
No
If yes, what percent is it? *
Are you training for a specific event? If yes, explain. *