|
Select the camp you wish to attend:
Two Week Membership: $129
1 Month Membership: $199
3 Month Membership: $499
|
|
Your Full Name:
Postal Address:
City:
ZIP Code:
Date of Birth:
E-mail Address:
Home Telephone Number:
Work Telephone Number:
Fax Number:
Is this your first gym membership? Yes No
If No, when did you last regularly attend a gym?
I rate my current fitness level as: (1-10, 10 being perfect
fitness)
I was referred by:
No Referral:
Friend or Existing Member:
Web Search:
Clipper Magazine:
Chamber of Commerce:
Brochure or Flyer:
Other: (Please Describe)
|
|
Primary Emergency Contact:
Primary Emergency Phone Number:
Secondary Emergency Contact:
Secondary Emergency Phone Number:
|
 | IMPORTANT! Please complete
this portion of the form completely. Grinder Gym and Dave DePew
Enterprises, Inc. shall not be held responsible in the event of medical
complications arising from having incompletely or inaccurately
completed the medical disclosures portion of this
form!
All attendees should seek medical
advice before beginning any health, fitness, or
nutrition program! |
Allergies
Are you allergic to any medication? (Aspirin, penicillin, sulfa,
etc.)
Medications
Do you take any prescribed medication on a permanent or semi-permanent
basis?
Epilepsy
Do you have a seizure disorder and/or epilepsy? Yes: No:
Diabetes
Do you have diabetes? Yes: No:
If yes, please list your diabetes
medications:
Anemia
Have you ever been found to be anemic? (Low blood count) Yes: No:
High Blood Pressure/Hypertension
Do you have High Blood Pressure? (hypertension) Yes: No:
If yes, please enter your hypertension medications:
Diseases
Do you have, or have you ever had, the following diseases?
Heart Disease: Yes No Lung Disease: Yes No
Liver Diesease: Yes No Kidney Disease: No
Do you have asthma? Yes: No:
Have you ever had a severe neck injury? If so, please describe:
Have you ever been knocked out or had a concussion? If so, please
describe:
Do you wear prescription contact lenses or eyeglasses? Yes:
No:
Have you had a broken bone or fractured bone within the last two
years? If so, please describe:
Have you ever injured your back? If so, please describe:
Do you have back pain?
Never:
Seldom:
Occaisionally:
Frequently with vigorous exercise or heavy lifting:
Have you had knee problems in the past 2 years that disabled you for
longer than a week? If so, please describe:
Please detail any surgical procedures you've had:
Do you have any other physical conditions which cause pain, or other
medical concerns about which we should be aware? If so,
please describe:
Finally, what are your fitness goals for the next three
months?
|
|
This release is entered into between the undersigned and Grinder Gym
(division of Dave DePew Enterprises, Inc.) its officers, trainers,
affiliates,
trainers and executors in addition to the City of San Diego, and all
other private and public locations for Dave Depew Enterprises, Inc and
the
county of San Diego. The purpose of Dave Depew Enterprises, Inc is to
provide
fitness 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 no fitness trainer or instructor is 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 Dave Depew Enterprises,
Inc
does not guarantee neither good nor bad will occur nor guarantees the
training advice given by Dave Depew Enterprises, Inc 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. Videography and photography may be taken at various camp locations
which may appear on TV, web video, print or any other digital format.
When possible, the camp participants will be told in advance of the days
in which any photography or videography will be done. "Before & after"
photos will not be used for any promotional purposes unless written
authorization is granted.
5. 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 ones 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 Dave DePew
Enterprises, Inc
for the undersigned participating in said sporting events and/or
training for said sporting events.
6.) Grinder Gym, Dave Depew Enterprises, Inc, and/or Dave DePew,
Inc. are not responsible or liable for fitness or bootcamp instruction
time that
is not used due to any action or inaction on the behalf of the attendee,
nor for any disruption of the gym, training, instruction, or boot camp
arising from events beyond the
control of Gym Management, including emergencies and/or acts of
God. Attendee acknowledges and warrants that any refunds for Grinder Gym
attendance or inattendance will be at the sole discretion of Grinder Gym
Management.
The Undersigned agrees and warrants that this is the full agreement
between the parties, that Dave Depew Enterprises, Inc, nor anyone else
has not verbally
contradicted any of the terms of this release and that the undersigned
has entered into this agreement freely and voluntarily without force or
coercion.
Check the following to acknowledge your intention to adhere to the
Honor Code:
I
agree to
abstain from consumption of all alcoholic beverages while at
Grinder Gym, or participating in Grinder Gym activities or training.
(If Applicable.)
I
agree that I will follow my nutrition manual and make my nutrition
manual available for review at all times by my instructors or
trainers. (If applicable.)
I
agree to only eat the preferred foods during the course of my time
in Training. (If applicable.)
I
agree to
show up for scheduled training times and appointments unless it is an
excused absence from my
doctor, or pre-approved with Training Instructors. (If applicable.)
I
agree to
respect training instructors and my fellow attendees by setting my alarm
clock properly and showing up for scheduled appointments on-time, every
time.
| BY CLICKING SUBMIT, YOU AGREE TO ALL
OF THE ABOVE TERMS, CONDITIONS, POLICIES,
AND PROCEDURES OF THE GRINDER GYM AND DAVE DEPEW ENTERPRISES, INC. YOU
FURTHER WARRANT THAT YOU FULLY
UNDERSTAND ALL OF THESE TERMS AND CONDITIONS,
AND THAT YOU HAVE COMPLETED THE MEDICAL DISCLOSURES PORTION OF THE
REGISTRATION FORM TO THE FULLEST POSSIBLE EXTENT.
YOUR IP ADDRESS
WILL BE RECORDED AS PART OF YOUR
SUBMISSION. | |
|
Please enter your full name and last four digits of your
Social Security # to serve as your legally-binding digital
signature:
Type your full name here:
Enter the last four digits ONLY of your SSN here:
|
|