Secure SouthSide Boot Camp Registration Form Use this online form if you are paying by Paypal only.
First Name:
Last Name:
Address:
City:
Zip:
Profession:
Date of Birth: Yes, you must include the year!	Month  Day  Year
I'm signing up for this camp:	Choose Your Event Here! (MANDATORY) Camp 5, starts 05/05/2008 Camp 6A, starts 06/16/2008 Camp 6B, starts 06/16/2008 Camp 7A, starts 07/07/2008 Camp 7B, starts 07/07/2008 Camp 8, starts 08/04/2008
I'm signing up for how many days/week:	4 days per week
This is my first camp:	Yes No If you answered "no", when was the last camp you attended:
Emergency Contact & Phone:
Your Home Phone:
Work Phone:
Cell Phone:
Fax Number:
E-mail Address:
I rate my current fitness level as a:	1 2 3 4 5 6 7 8 9 10 (1-10), ten being high
I was referred by:
My main goal is to:
What was your search word, or how did you find us?
If using credit card please call 773-572-7133.  We have a POS terminal available for credit card processing.  We can accept Visa/MasterCard/Discover/American Express.   If paying by check, please make payable to: TEAM S.P.E.E.D. LLC. Will be collected 1st day of Camp. Confirmations and detailed instructions will be mailed prior to the start of Boot Camp.  Waiver must be signed prior to participation.
MEDICAL HISTORY If you are returning and have no medical changes, the section below does not need to be completed. All agreements remain the same. 1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?     Please list  2. Do you take any prescribed medication on a permanent or semi-permanent basis?      3. Do you have a seizure disorder (epilepsy)? Yes No 4. Do you have diabetes Adult or Juvenile? Yes No     List Medications: 5. Have you ever been found to be anemic (low blood count)? Yes No 6. Do you have High Blood Pressure (hypertension)? Yes No      List Medications: 7. 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 8. Do you have asthma? Yes No. List Medications: 9. Have you ever had a severe neck injury? Describe: 10. Have you ever been knocked out? Describe: 11. Do you wear glasses or contact lenses? Yes No 12. Have you had a broken bone or fracture in the past 2 years?      Describe: 13. Have you ever injured your back? Describe: 14. Do you have back pain? Never    Seldom    Occasionally    Frequently with 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?      Describe: 16. Do you have other physical conditions which cause pain? Describe: 17. Detail any surgical procedures: 18. What are your goals for the next three months? 19. Have you had your body fat tested? Yes No / If yes, what percent is it?       20. Are you training for a specific event?    NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!
RELEASE This release is entered into between the undersigned and Tony Simmons and TEAM S.P.E.E.D. LLC, its officers, trainers, affiliates, executors in addition to the City of Chicago. The purpose of TEAM S.P.E.E.D. LLC 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 Tony Simmons is not 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 Tony Simmons and TEAM S.P.E.E.D. LLC does not guarantee neither good nor bad will occur nor guarantees the training advice given by Tony Simmons and TEAM S.P.E.E.D. LLC 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. 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 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 Tony Simmons and TEAM S.P.E.E.D. LLC for the undersigned participating in said sporting events and/or training for said sporting events. The Undersigned agrees that this is the full agreement between the parties, that Tony Simmons, 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. Initial the following: I agree that I will not consume alcohol during the month of Boot Camp. Any violation will result in twenty push-ups per occurrence. I agree not to use foul language during Boot Camp. Any violation will result in twenty push-ups per occurrence. I agree not eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of Boot Camp. Any violation will result in twenty push-ups per occurrence. I agree to show up for Boot Camp every day unless it is an excused absence from my doctor or pre-approved with Boot Camp directors. Any violation will result in twenty push-ups per occurrence. I understand that photos or video may be taken during the course of my involvement in Boot Camp, which may be used for promotional purposes. I understand that my "before & after" photos will not be used for any promotional purposes unless I give written authorization. I understand there is no refund policy, but I can receive a credit (for unused portion of camp) towards a future camp if I'm not able to complete the one I originally joined. Camp fees CAN NOT be used towards any other products or services provided by Tony Simmons and TEAM S.P.E.E.D. LLC. I will remember to set my alarm and be at camp on time. Your signature will be required at the time of your evaluation and you agree to the terms now!  ____________________ Signature  ____________________ Printed Name ____________________ Date (By submitting this form, you are agreeing to all of the above!)

Lose Weight, Feel Great! Expected results when you complete camp are:   • 3-5% reduction in body fat   • Greatly Improved Posture   • Better Relaxation   • 5-12 pounds of weight loss   • 1-3 inch decrease in the midsection   • 25% improvement in endurance   • 25% increase in strength   • and 100% gain in self-confidence!