Merlin Hahn, Personal Training, Fitness Boot Camp, Fitness Retreats, Fitness Vacations, Boot Camp Exercise, Fox Valley Adventure Boot Camp

12 Week Transformation REGISTRATION

(If you are signing up 911 Fitness Challenge click drop down box)

Register Online
Fill out the online form below to register via internet. Click on Submit to go to the payment page.
CLICK ON Pay via Paypal , M/C, Visa, Amex.to view payment page Choose from drop down box and finish your online registration. A PayPal account is not required to pay via PayPal.

1 to 1 Fitness Inc.
2642 Havens Dr
West Chicago IL, 60185
1to1fitness@comcast.net
Phone: (630) 640-0467

Fill out the form below and Click on SUBMIT.
You must be 18 years of age or older to enter.

You will be notified to schedule your pre- evaluation (if needed for your program).
Name
Address
City
State
Postal code
Profession
Why do you want to enroll?
Date of Birth	(mm/dd/yyyy)	Age
Phone Number		Work Number
Fax Number
Email Address
Team Name
I rate my current fitness level as a (1-10), ten being high.
I was referred by:
How did you hear about us?: Blast fax , friend , Ad		Please specify publication / website / friend ,key words searched or other referral:
This is my first time training:	Yes \| No	If you answered "no", when was the last camp you attended:
My Main goal is:
Name of Emergency Contact & Phone Number
What is the name of the program from drop down box.

Form of payment:		Payment Options:
12 Week Transformation MUST BE SUPERVISED WEEKLY. WEEKLY FOOD JOURNALS MUST BE COMPLETED. Program Includes: 12 week digtial workout file program. Supportive audio files dealing with eating and exercise strategies. A pantry raid. A Grocery tour. And a Physical assessment. This program is designed to foster ongoing physical improvement and to deliver results. Email me to set up an appointment to go over the details at 1to1fitness@comcast.net MEDICAL HISTORY
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
List Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
List Medications:
3. Do you have a seizure disorder (epilepsy)?
List Medications:
4. Do you have diabetes Adult or Juvenile?
5. Have you ever been found to be anemic (low blood count)?
6. Do you have High Blood Pressure (hypertension)?
List Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:
8. Do you have asthma?
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?
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?
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?		If yes, what percent is it?
20. Are you training for a specific event? If yes, explain:
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 Adventure Boot Camp, its officers, subsidiaries, affiliates, and executors in addition to the Cities of Batavia,Geneva,St Charles and Wheaton and Lincolnshire . The purpose of Adventure Boot Camp and 1to1 fitness is to provide fitness instruction and coaching for various levels of athletes/individuals. At all times you agree 100% that you take full responsibility for yourself and your safety. The undersigned hereby acknowledge that the following was explained to me and/or agree to the following: 1. Acknowledges that Merlin Hahn 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 Adventure Boot Camp and 1to1 fitness does not guarantee neither good nor bad will occur nor guarantees the training advice given by Merlin Hahn including Adventure Boot Camp 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 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 Adventure Boot Camp 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 Adventure Boot Camp, and 1to1 fitness including Merlin Hahn 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 coercion. . Checkmark the following: I understand that photos or video will be taken during the course of my involvement in The 12 Week Tranformation,which may be used for promotional purposes. I understand that my "before & after" photos will be used for any promotional purposes. I understand there is no refund policy,all payments for the 12 Week Tranformation must be made in full or in 3 installments in 3 WEEKS. Even if I decide to quit. In addition any unused sessions become null and void after 60 days if I'm not able to complete the one I originally joined. Fees can not be used towards any other products or services this provided by Merlin Hahn, Adventure Boot Camp,and 1to1fitness. I understand that diet and nutrition will effect my fitness goals and performance.. I understand their is a 24 hour canellation policy. If I cancel a scheduled session I will be charged unless I give 24 hours notice in writting via email. All correspondance will be directed to 1to1fitness@comcast.net
I agree to all Terms and Conditions listed above Electronic Signature Date (MM/DD/YYYY)