EXTREME HEALTH BOOTCAMP REGISTRATION FORM

Given Name: Male ___________________________________ Surname: ____________________________________ Female DOB: __ / __ / __

I am registering for the Extreme Health Boot Camp challenge starting: (please insert start date): _____________________ Telephone: H: _______________________ W: ______________________ M: _________________________

Email: _______________________________________________________________________________________ Address: ______________________________________________________________________________________ Emergency Contact: ____________________________ Relationship: ____________________________________ Telephone: H: _______________________ W: ______________________ M: _________________________

Medical Conditions: (past or present) __________________________________________________________________ Conditions of Engagement (please confirm with tick): I understand that I am required to attend 2 training sessions per week for 8 weeks and commit to give 100% at each session. I agree that Extreme Health Boot Camp has advised me that this is a rigorous fitness program and I accept total responsibility for participation in all exercises. I understand that the trainers (Richard Ketchell or Jo Carmen) are not a physician and any information given in regards to a medical condition, including injury is to be used as a guide only and should be followed up with your doctor. I understand that if I feel pain or feel out of the ordinary in any way either related to my training, or otherwise, that I should advise the trainers immediately. I understand that diet and nutrition will affect my fitness goals and performance during boot camp. I choose to commit to eating well and exercising outside of boot camp hours. I understand that photos may be taken during the course of my involvement in Boot Camp, which may be used for promotional purposes. I understand there is no refund once I commence the challenge. I understand that Extreme Health Boot Camp reserves the right to change the program format and accepts no responsibility for participants health, safety, injuries or loss during the duration of the 8 week program. PLEASE NOTE: Places are limited: Full payment and completed registration forms must be received at least one week prior to the scheduled start date in order to secure your place. Your payment is non-refundable: If you are unable to attend Boot Camp after making payment, you can transfer to a later date at no extra charge, providing you notify us at least one week prior to the scheduled start date. Transfers after this date will incur a minimum $20 transfer fee. Minimum numbers are required: In the unlikely event that minimum numbers have not been met at least one week prior to the scheduled start date, we will postpone the start date by at least one week until minimum numbers are met. I ___________________________ herewith agree to fully indemnify Richard Ketchell, Jo Carman, Narmin Hanna, Extreme Health Boot Camp, and any subsidiaries, affiliates, employees, agents and any other persons affiliated with Extreme Health Boot Camp. I acknowledge that I am fit and able to commence training and have been advised by the trainers that I should consult with my Doctor before commencement of the BOOT CAMP Program. Activities conducted by Extreme Health BOOT CAMP are undertaken at my own risk. Signed: __________________________________________ Date: ____________________________________

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EXTREME HEALTH BOOT CAMP PRE EXERCISE QUESTIONNAIRE

EXERCISE HISTORY
Have you been exercising regularly? Yes How often: ___________ Type of exercise: _________________________________________ No When was the last time you exercised: _______________________________________________

LIFESTYLE AND MEDICAL CONSIDERATIONS

YES Are you taking any prescribed medication? Are you currently carrying an injury? Have you suffered or do you suffer from back pain? Do you smoke? Are you pregnant? Are you a non-exercising male over 35 or female over 45? Does anyone in your family have high blood pressure? Are they on medication? Do you suffer from asthma attacks? Do you suffer from diabetes? Has anyone in your family under 60 suffered any heart condition or stroke? NO If Yes details

PLEASE INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:

Gout Stroke Chest pain Epilepsy Hernia Glandular fever Rheumatic fever Dizziness or fainting Stomach or duodenal ulcer Liver or Kidney problems Any heart condition Heart murmur High blood pressure Asthma or wheezing Raised cholesterol

If you answered yes to any of the above please provide details:

WHAT RESULTS DO YOU WANT TO ACHIEVE:

Weight Loss Improve self esteem Sports conditioning Increase size / Strength Other I hereby declare that the information I have provided on this questionnaire is true and correct. Reduce body fat Improve confidence Body sculpting / Shaping Increase energy levels Firm up / Increase body toning Stress management Increase endurance / stamina Look and feel good

______________________________________ Print Name

__________________________________ Sign

_______________ Date

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EXTREME HEALTH BOOT CAMP MEDICAL CONSENT FORM

Please read and sign the following:
I ____________________________________ of _________________________________________________ ______

understand that there exists the possibility that certain abnormal changes and risks may occur during training or testing sessions. I understand that I am responsible for monitoring my own condition throughout the tests and training sessions, and should any unusual symptoms occur, I will cease my participation and inform the trainer of the symptoms. Efforts will be made to minimize these occurrences by preliminary screening and precautions and observations during the testing or training. I understand and accept that the possibility may and does exist, that accidental or unavoidable discomfort or injury may occur. In the event that a medical clearance is required, I understand that it is my responsibility to ensure this clearance is obtained. Without a clearance I understand that Extreme Health Boot Camp may decide no further training for myself can take place until this medical clearance is obtained. I understand that this clearance will be treated as privileged and confidential, as will all other personal details and that these will not be released or revealed without my express written consent. I understand and agree that in the event of injury or illness, whilst in attendance at an Extreme Health Boot Camp, I give my permission for a representative of Extreme Health Boot Camp to make decisions on my behalf concerning the most appropriate action to be taken with respect to my condition. In signing this form, I affirm that I have read it in its entirety and that all my questions regarding the testing and proposed exercise regime have been answered to my satisfaction. My participation is totally voluntary; I know that I can discontinue my participation at any time without penalty. I agree to assume the risk of such testing and exercise, and further agree to hold harmless Extreme Health Boot Camp its subsidiaries, affiliates, employees, agents and any other persons associated from any and all claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims that may result from my injury or death, accidental or otherwise arising in any way from the testing or exercise regime. If you have / had any medical condition and/or are above 35 years of age do you have medical clearance to undertake regular and reasonable exercise? Tick and sign appropriate box YES _______________________________________________________________________________

If you tick and sign NO you acknowledge that we advise you to obtain suitable medical clearance NO _______________________________________________________________________________

_____________________________________________ Witnessed by (print name): for Extreme Health

__________________________________________ Sign:

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EXTREME HEALTH BOOT CAMP PAYMENT DETAILS

CANCELLATION POLICY Your payment is non-refundable: If you are unable to attend Boot Camp after making payment, you can transfer to a later date at no extra charge, providing you notify us at least one week prior to the scheduled start date. Transfers after this date will incur a minimum $20 transfer fee. PAYMENT DETAILS Payment can be made by (Please select one): Direct deposit Banking details: Bank of Queensland Account Name: Narmin Hanna BSB: 124-100 Account No: 20913028 (Please ensure you put your name as reference and BC following your name (i.e. NameBC)) Cheque Made payable to Narmin Hanna Cash Payment Plan (Please note, payment of $150 is payable upfront before commencing payment plan and a scheduled periodic direct
deposit must be agreed to and set up directly with your bank and must be finalised by week 4 of bootcamp). Please note, we do not mean to offend, but due to previous incomplete payments, if payment is not finalised by week 4, you will not be permitted to participate in further training sessions until the balance is paid.

I wish to pay $ __________________ per week fortnight for

___________________ instalments.

My first instalment will commence:________________ (date) and cease: __________________ (date)

PLEASE INDICATE YOUR PREFERRED SESSION Southside Hardy Road, Mt Sheridan Beaches Monday Weigh in Tuesday, Thursday Tuesday, Trinity Beach Wednesday, Weigh in Yorkeys Knob Community Centre Thursday, Kewarra Beach 5:30 to 6:30pm 6pm to 7pm 5:45 to 6:45pm 5:30 to 6:30pm 5:45 to 6:45am

I understand and have signed all forms:

I have read & understand the cancellation policy:

Signed: Date:

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