Women's Adventure EZ8 Running in New Jersey, bootcamp for women, adventure boot camp, womens fitness program, womens weight loss, exercise camp, womens camp, exercise, workout programs, outdoor exercise

Registration and Release Form

New Jersey 's Best Women's Running Group

You now have 2 options:
A. You can print this form and send it in with payment by mail
B. Register Online
Fill out the online form below to register via internet. Click on Submit to go to the payment page.
Payment Page: Pay via Paypal. Choose your class and finish your online registration. A PayPal account is not required to pay via PayPal.

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received payment.

A. CHECK – please make your check payable to: NJ EZ8 Running Camp and mail with your completed registration form to: NJ EZ8 Running Camp: Attn: Valerie Pawlowski, PO Box 609,Peapack, NJ 07977

B. CREDIT CARD – For “SECURE” online payment using VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS or PayPal, select $199 EZ8 Running (2 days/week), or $99 Novice Runner (2 days/week)

NJ EZ8 Running Camp
c/o Valerie Pawlowski
PO Box 609
Peapack, NJ 07977
Phone (800) 940-9149
Fax (908) 234-9112

You will be notified to schedule your pre-camp evaluation (if needed for your program).

Name Date:

Address

City

State

ZIP

Profession

Date of Birth (mm/dd/yyyy)

Phone Number Work Number

Fax Number

Email Address

I can run a minute/mile.

I rate my current fitness level as a (1-10), ten being high.

I was referred by:

How did you hear about us?: Please specify publication / website / friend or other referral:

This is my first camp: 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 that you are joining?

Start Date: Camp Name:

Program: Form of payment:

MEDICAL HISTORY (If you are a returning camper, only complete the sections that have changed.)

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

2. Do you take any prescribed medication on a permanent or semi-permanent basis?

3. Do you have a seizure disorder (epilepsy)?

4. Do you have diabetes Adult or Juvenile? List Medications:

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? 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?

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:

21. What do you think your timed mile will be?

22. How much have you been running lately?

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 New Jersey/NJ EZ8 Running Camp, its officers, subsidiaries, affiliates, and executors in addition to Far Hills, Bedminster, Peapack and Gladstone, Bernards Township and the county of Somerset. The purpose of NJ EZ8 Running Camp 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 Valerie Pawlowski or Shari Sperandio 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 Valerie Pawlowski or Shari Sperandio will provide fitness instruction and coaching to the undersigned, but that Valerie Pawlowski or Shari Sperandio does not guarantee neither 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. Acknowledge that the undersigned will not hold NJ Adventure Boot Camp, NJ EZ8 Running Camp, The Body Barn or any of its affiliates liable for injury, loss or work, or death.

5. Acknowledges that the undersigned assumes the risks of participating in fitness training, 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 Valerie Pawlowski or Shari Sperandio 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 Valerie Pawlowski or Shari Sperandio, 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 there is no refund policy.

I will remember to be at set location at designated time.

I will be dedicated to this program and give my very best.

I will have FUN!

Electronic Signature

Date (MM/DD/YYYY)

I agree to all Terms and Conditions listed above

For More Information, call us at 1-800-940-9149 or