Date of Birth:
I rate my current fitness level as a:
(1-10), with 10 being highest.
I was referred by:
Emergency contact and phone number:
Boot Camp Location
CrossFit 12330 SW 53 St # 708, Cooper City,
5:30am - CrossFit / Flamingo Park - Cooper City
930am - CrossFit / Flamingo Park - Cooper City
630pm - CrossFit / Flamingo Park - Cooper City
(If you are a
returning camper, only complete the sections
that have changed.)
1. Are you allergic to any
medication (aspirin, penicillin,
2. Do you take any prescribed
medication on a permanent or
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes Adult or
5. Have you ever been found to be anemic (low
6. Do you have High Blood Pressure
7. Do you have or have you ever had
the following diseases?
8. Do you have asthma?
9. Have you ever had a severe neck
10. Have you ever been knocked out?
11. Do you wear glasses or contact
12. Have you had a broken bone or
fracture in the past 2 years?
13. Have you ever injured your back?
14. Do you have back pain?
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?
16. Do you have other physical
conditions which cause pain?
17. Detail any surgical procedures:
18. What are your goals for the next three months?
19. Have you had your body fat
If yes, what percent is it?
20. Are you training for a specific
If yes, explain:
NOTICE: It is wise to seek your
doctor’s advice before beginning any
This release is entered into between
the undersigned and 911 FITNESS,
its officers, subsidiaries,
affiliates, and executors in addition to
the City of Pembroke Pines, Weston, and
the county of Broward.
The purpose of 911 FITNESS
is to provide fitness instruction
and coaching for various levels of
The undersigned hereby acknowledge
that the following was explained to me
and/or agree to the following:
Acknowledges that Jim
LEAD Trainer for
911 FITNESS, is not a
physician and is not trained in
any way to provide medical
diagnosis, medical treatment, or
any other type of medical
advice. Acknowledges that
coaching/training is another tool
for teaching athletes/individuals
about themselves, but that does not
guarantee neither good nor bad will
occur nor guarantees the
training advice given will produce
good nor bad results. Acknowledges that the
undersigned has been told if they
feel tired, feel pain or feel out of
in any way either related to your
training, or otherwise, that the
undersigned should contact a
physician at once. 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
elements of a natural environment,
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 Jim Sayih or 911
Fitness for the undersigned
participating in said sporting
events and/or training for said
The Undersigned agrees that
this is the full agreement
between the parties, that 9
FITNESS and Jim Sayih,
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
By typing your name in this
field, you are hereby giving a