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Personal details
Name *
Date of Birth *
Gender *
Address *
Suburb *
Home Phone
Mobile *
Work Number
Which Boot Camp are you enlisting for? *
What sort of training have you been doing?
What are you hoping to get out of Boot Camp?
Do you suffer from: *
(Please check those that apply)
Is there a family history of heart disease or heart condition ? *
Do you suffer from *
Do you have any major injuries? *
If yes, please add details
Do you suffer from any of the following conditions? *
Have you been hospitalised recently? *
Is There Anything That May Affect The Way You Participate In This Program: *
If yes, please describe.
Are You Pregnant? *
Are You Male >35 and Unaccustomed to Exercise? *
Are you Females >45 and Unaccustomed to Exercise? *
Terms and Conditions *
I hereby represent to Daniel Clifton-Northey and Byron Bay Camp (BBBC), its management, associated companies, trusts, partnerships and other legal entities, their directors, officers, employees, agents and affiliates, that I am physically capable of and there is no medical reason to prevent me from proceeding with any Daniel Clifton-Northey and BBBC program without endangering my health. I acknowledge that whilst participating in the program, my person and my property are at my own risk. I acknowledge that I will not hold Daniel Clifton-Northey Personal Training responsible for and Daniel Clifton-Northey and BBBC hereby excludes Daniel Clifton-Northey and BBBC, to the extent permitted by law, all liability for any personal injury or damage (whether direct, indirect, special or consequential) suffered by me while I am participating in the Daniel Clifton-Northey and BBBC program., however that injury, damage or loss is caused, including if it is caused by the negligence of Daniel Clifton-Northey. I acknowledge that except as provided in this document Daniel Clifton-Northey and BBBC give no warranty in respect to the services and equipment it provides. I hereby release and will indemnify Daniel Clifton-Northey and BBBC for any injury or loss suffered by me whilst participating in the Daniel Clifton-Northey and BBBC program.
Date *
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