Berthoud Athletic Club - Abdominal and Pelvic Floor Boot Camp Registration Form

First Name:	Last Name
2009/2010 Boot Camp Sessions
Contact Information
Address:
City:
State:
Zip:
Email:
Home Phone:
Work Phone:
Cell Phone:
Emergency Contact Information
Emergency Contact's First Name:	Emergency Contact's Last Name
Home Phone:
Work Phone:
Cell Phone:
$20 Deposit Payment Information
Please note that you must pay a $20 deposit to guarantee your Boot Camp Registration. If you choose not to include your credit card information on this form, you may mail or drop off your deposit payment to Berthoud Athletic Club. Please note that SPACE IS LIMITED – your place in class is not guaranteed until we receive your deposit payment.
Please Choose Payment Method	Check	Credit Card
If you wish to pay by Credit Card, please select:	VISA	MASTERCARD
CC Number:	Expiration Date:
Waiver Agreement
I hereby waive for myself, my heirs, my child, my executors and administrators forever, all claims for damages against Berthoud Athletic Club (BAC), its officers, directors, shareholders, or agents from, or in any way connected with, any and all injuries which may be suffered on or incurred while participating in activities, whether or not authorized by BAC, or by utilizing any of the facilities at its athletic club, or its premises. This waiver shall be applicable even if my injuries arise from the negligence of BAC, its officers, directors, shareholders, employees or agents.
YES, I agree to these terms.