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This page was last updated: June 29, 2010

PRACTICAL

PERSONAL

TRAINING

Denise Woollard

Hampshire, Illinois 60140

Phone: (847) 363-8294

Fax: (847) 683-3814

Training Hours:

By Appointment

We want to hear from you. Let us know how we are doing. We need your feedback whether positive or negative. So send us an email.

Contact Us

Boot Camp Registration

Name_____________________________________________________Date_____________________

Address____________________________________________________________________________

Phone#_______________________________Email address__________________________________

Age____________   DOB__________________

Occupation(if applicable)______________________________________________________________

Do you currently work out?___________If so, how often_____________________________________

What activities do you participate in?_____________________________________________________

Are you able to run or jog 1-2 miles without stopping?___________

Do you have or have you had any medical issues?___________ (check all that  apply with an X )

Heart Disease_____  Diabetes_____  High Blood Pressure_____  Thyroid issues_____

Asthma_____  Arthritis_____  Cancer_____   Stroke_____   Other_____

Explain:______________________________________________________________________________

____________________________________________________________________________________

Have you had any recent surgeries or past injuries?_________(check all that apply with an X)

Back_____  Shoulder_____  Neck_____  Elbow_____  Wrist_____  Knee_____  Ankle_____  Foot_____

Head_____  Hip_____  Other_____

Explain:____________________________________________________________________________

___________________________________________________________________________________

Are you on any medications that can have an effect on your heart rate or your ability to work out?_____

If so, please list and explain:_____________________________________________________________

___________________________________________________________________________________

Upon completion of this form please hit the submit button.  Once we have received your registration form and have verified your payment you will recieve an email to confirm your registration.