Melrose Boot Camp Signup Form

Member’s Area

Upcoming MBC Events

	First Name*
	Last Name*
	Email*
	Address*
	City*
	State*
	Zip*
	Phone*
	Age*
	Weight (lbs)*
	Height *
	Emergency Contact*
	Emergency Phone Number*
	Current Medications*
	Medical Limitations*
	Running Currently
	Running HS or College
	Sports Played in Past*
	Current Sports, Workouts, Training*
	Injuries, Pain, Surgery*
	Heart Condition*		yes no
	High Blood Pressure*		yes no
	High Cholesterol*		yes no
	Stroke*		yes no
	Heart Attack*		yes no
	Chest Pain with Exercise*		yes no
	Chest Pain at Rest*		yes no
	Emphysema*		yes no
	Chronic Bronchitis*		yes no
	Diabetes*		yes no
	Pregnant*		yes no
	Smoker*		yes no
	Family Member Heart Attack*		yes no
	Please explain any ‘Yes’ answers above*
	Reason why you can’t or shouldn’t participate*
	Anything Else We Should Know*
	How did you hear about us?*
	Date*
	Waiver Signature (I agree with the waiver below)*		yes no
	Verification code*

Melrose Boot Camp