Registration

Please complete the registration and health information form below, if you have not done so already.

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I am a...* *

Please Enter The Dates You Need To ReBoot *

Name *

First

Last

Email *

Address *

Line 1

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City

State

Zip Code

Country

Phone Number *

Emergency Contact Information

Contact Name *

First

Last

Phone Number *

Contact Name *

Medical History - Note: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!

Do you have any medical condition we should be aware of? *

No Yes

Do you have any injuries we should be aware of? *

No Yes

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

No Yes

Do you regularly take any prescription medications? *

Do you have any injuries? *

Personal Information

Height *

Weight *

Needed if you want to surf, race cars, equipment, paddleboard and/or kayak

T-Shirt Size *

ReBoot Camp Retreat Questionnaire

Would you like to take *

French Lessons Cooking Lessons Race Car Driving

Fitness/Goal Information

Describe Your Fitness: Include the activities in which you participate (e.g. running, hiking, walking, biking, skiing, aerobics, swimming, yoga, pilates, etc.), the frequency with which you participate in each activitiy (i.e. how often, how far, for how long), the duration of your fitness program, and any other information you woud like us to have. *

Your Intention! What do you hope to accomplish and/or learn at the retreat? *

Describe your intentions, goals, and wild visions for the retreat!* *

Is there any activity that you are particularly eager to experience at this retreat? *

Do you have any questions or concerns? *

Please call us if you'd like to discuss any questions or concerns. Is there anything else you would like us to know about you? *

How did you hear about ReBoot Camp Retreats?? *

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