<form action="processor.php" enctype="multipart/form-data" method="post">
<h1>General Information</h1>
<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td align="right">Name:</td>
<td align="left"><input id="txtName" type="text" /></td>
</tr>
<tr>
<td align="right">Address:</td>
<td align="left"><input id="txtAddress" type="text" /></td>
</tr>
<tr>
<td align="right">City:</td>
<td align="left"><input id="txtCity" type="text" /></td>
</tr>
<tr>
<td align="right">State:</td>
<td align="left"><input id="txtState" type="text" /></td>
</tr>
<tr>
<td align="right">ZIP:</td>
<td align="left"><input id="txtZIP" type="text" /></td>
</tr>
<tr>
<td align="right">Profession:</td>
<td align="left"><input id="txtProfession" type="text" /></td>
</tr>
<tr>
<td align="right">Date of Birth:</td>
<td align="left"><input id="txtDOB" type="text" /> (MM/DD/YYYY)</td>
</tr>
<tr>
<td align="right">Phone Number:</td>
<td><input id="txtPhoneNumber" type="text" /></td>
</tr>
<tr>
<td align="right">Work Number:</td>
<td align="left"><input id="txtWorkNumber" type="text" /></td>
</tr>
<<tr>
<td align="right">Cell Number:</td>
<td align="left"><input id="txtCellNumber" type="text" /></td>
</tr>
<tr>
<td align="right">Fax Number:</td>
<td align="left"><input id="txtFaxNumber" type="text" /></td>
</tr>
<tr>
<td align="right">Email Address:</td>
<td align="left"><input id="txtEmailAddress" type="text" /></td>
</tr>
<tr>
<td align="right">Reffered by:</td>
<td align="left"><input id="txtRefferedBy" type="text" /></td>
</tr>
<tr>
<td colspan="2" align="left">Rate your current fitness level between 1 and 10, 10 being great.
<select id="CurrentFitnessLevel">
<option value="" selected="true"></option>
<option value="01">1</option>
<option value="02">2</option>
<option value="03">3</option>
<option value="04">4</option>
<option value="05">5</option>
<option value="06">6</option>
<option value="07">7</option>
<option value="08">8</option>
<option value="09">9</option>
<option value="10">10</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">How did you hear about us? <input id="txtHearAboutUs" type="text" /></td>
</tr>
<tr>
<td colspan="2" align="left">Is this your first Cardio Bootcamp?
<select id="FirstBootcamp">
<option value="No" selected="true">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">If no, when was your last camp? <input id="txtLastBootCamp" type="text" /></td>
</tr>
<tr>
<td colspan="2" align="left">
What is your main goal for participating in this boot camp?<br />
<textarea id="txtareaGoalForParticipation" cols="45" rows="10"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">Name of Emergency Contact: <input id="txtEmergencyContactName" type="text" /></td>
</tr>
<tr>
<td colspan="2" align="left">Number for Emergency Contact: <input id="txtEmergencyContactNumber" type="text" /></td>
</tr>
</table>
<br />
<h1>Medical History</h1>
<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td colspan="2" align="left"><i>IF YOU ARE A RETURNING PARTICIPANT, ONLY COMPLETE SECTIONS THAT HAVE CHANGED.</i></td>
</tr>
<tr>
<td colspan="2"></td>
</tr>
<tr>
<td colspan="2" align="left">
Please list any medications you are allergic to.<br />
<textarea id="MedicationAllergies" cols="45" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Please list any prescribed medications that your on a perminant or semi-perminant basis.<br />
<textarea id="PrescribedMedicatons" cols="45" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
If you have a seizure disorder, please list medications.<br />
<textarea id="SeizureMedications" cols="45" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you have any form of diabetes?
<select id="DiabetesForm">
<option value="None" selected="true">None</option>
<option value="Juvenile">Juvenile</option>
<option value="Adult">Adult</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you even been found to be anemic (low blood count)?
<select id="Anemic">
<option value="No" selected="true">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you take any medications for high blood presure (hypertension)? If yes, please list.<br />
<textarea id="HighBloodPresureMedications" cols="45" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you, or have ou ever had, any of the follwoing diseases? Select all that apply.<br />
<input id="chkbxHeartDisease" type="checkbox" /> <i>Heart Disease</i><br />
<input id="chkbxKidneyDisease" type="checkbox" /> <i>Kidney Disease</i><br />
<input id="chkbxLungDisease" type="checkbox" /> <i>Lung Disease</i><br />
<input id="chkbxLiverDisease" type="checkbox" /> <i>Liver Disease</i><br />
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you take any medications for asthma? Please list.<br />
<textarea id="AsthmaMedications" cols="45" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you ever had a severe neck injury?
<select id="HaveHadNeckInjury">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="NeckInjuryDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you ever been nocked out?
<select id="HaveBeenNockedOut">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="NockedOutDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you wear contact lenses or glasses?
<select id="ContactsGlasses">
<option value="No">No</option>
<option value="Contacts">Contacts</option>
<option value="Glasses">Glasses</option>
<option value="Both">Both</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you ever had a broken bone or fracture in the past 2 years?
<select id="HadBrokenFractureBone">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="BrokenFractureBoneDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you ever injured your back?
<select id="HadBackInjury">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="BackInjuryDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you have pack pain? <i>Pick one.</i>
<select id="BackPain">
<option value="Never">Never</option>
<option value="Seldom">Seldom</option>
<option value="Occassionally">Occassionally</option>
<option value="Frequently">Frequently</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you ever had knee pain in the past 2 yaers that has disabled you for longer than a week?
<select id="HadKneePains">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="KneePainDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Do you have other physical conditions which cause pain?
<select id="OtherPains">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="OtherPainsDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Detial any surgecial procedures:<br />
<textarea id="SurgecialProcedureDescriptions" cols="45" rows="10"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Have you ever experienced any type of heat illness (heat stroke or heat exhaustion)?
<select id="HadHeatIllness">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="HeatIllnessDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="left">
Are you training for a specific event?
<select id="TrainingForSpecificEvent">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<i>If so, describe:</i><br />
<textarea id="TrainingEventDescription" cols="40" rows="5"></textarea>
</td>
</tr>
<tr>
<td colspan="2"></td>
</tr>
</table>
<br />
<h1>Release</h1>
<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td colspan="2" align="left">
<p>
<b>Notice:</b> It is wise to seek your doctor's advice beginning any health/fitness/nutrition program.
</p>
<p>
This release is entered into between the undersigned and Cardio Inc, LLC, its officers, subsidiaries, <br />
affiliates, and executors. The purpose of Cardio Inc Boot Camp is to provide fitness instructions and <br />
coaching for various leveles of atheletes/individuals.<br /><br />
The undersinged hereby acknowledge that the following was explained to me and/or agree to the following:
</p>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<div class="terms">
<table border="0" cellpadding="3" cellspacing="0">
<tr>
<td valign="top" align="left">I.</td>
<td align="left">
Acknowledges that Cardio Inc Boot Camp instructors are not physicians and are not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
</td>
</tr>
<tr>
<td colspan="2" align="left"></td>
</tr>
<tr>
<td valign="top" align="left">II.</td>
<td align="left">
Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Cardio Inc Boot Camp does not guarantee neither good nor bad will occur nor guarantees the training advice given by Cardio Inc Boot Camp instructors nor Cardio Inc Boot Camp will produce good nor bad results.
</td>
</tr>
<tr>
<td colspan="2" align="left"></td>
</tr>
<tr>
<td valign="top" align="left">III.</td>
<td align="left">
Acknowledges that the undersigned has been told if they feel tired, feel pain or feel out of the ordinary in any way either related to your training, or otherwise, that the undersigned should contact a physician at once.
</td>
</tr>
<tr>
<td colspan="2" align="left"></td>
</tr>
<tr>
<td valign="top" align="left">IV.</td>
<td align="left">
Acknowledges that boot camps, aerobic classes, kick boxing, running, weight training, obstacle courses, and any other related sports are an extreme test of one's mental and physical limits and carry with it potential for damage or loss of property, serious injury and death. That the undersigned assumes the risks of participating in these types of events/activities including the elements of a natural environment, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Cardio Inc Boot Camp for the undersigned participating in said sporting events and/or training for said sporting events.<br /><br />
The Undersigned agrees that this is the full agreement between the parties, that Cardio Inc Boot Camp including neither its instructors nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.<br /><br />
Customer client agrees to confidentiality with respect to Cardio Inc Boot Camp and all services provided by same. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of Cardio Inc Boot Camp. The undersigned agrees to a non-compete within a 50 mile radius of Wichita Falls for a period of 5 years from date of participation.
</td>
</tr>
</table>
</div>
</td>
</tr>
<tr>
<td align="left">
<table border="0" cellpadding="5" cellspacing="5">
<tr>
<td align="left">
<input id="chkbxLanguageAgree" type="checkbox" />
</td>
<td align="left">
<p>I agree not to use foul language during Boot Camp. Any violation will result in twenty push ups per occurrence.</p>
</td>
</tr>
<tr>
<td align="left">
<input id="chkbxWordsAgree" type="checkbox" />
</td>
<td align="left">
<p>I agree not to eat or say the words Twinkie, Donuts, Ho-Ho's, Ding Dong, or Cup Cake during the course of<br /> Boot Camp. Any violation will result in twenty push ups per occurrence.</p>
</td>
</tr>
<tr>
<td align="left">
<input id="chkbxShowUpAgree" type="checkbox" />
</td>
<td align="left">
<p>I agree to show up for Boot Camp every day unless it is an excused absence from my doctor or pre-approved<br /> with Boot Camp directors. Any violation will result in twenty push-ups per occurrence.</p>
</td>
</tr>
<tr>
<td align="left">
<input id="chkbxPhotosVideoAgree" type="checkbox" />
</td>
<td align="left">
<p>I understand that photos or video may be taken during the course of my involvement in Boot Camp, which may<br /> be used for promotional purposes. I understand that my "before & after" photos will not be used for any<br /> promotional purposes unless I give written authorization.</p>
</td>
</tr>
<tr>
<td align="left">
<input id="chkbxSetAlarmAgree" type="checkbox" />
</td>
<td align="left">
<p>I will remember to set my alarm and be at camp on time.</p>
</td>
</tr>
<tr>
<td align="left">
<input id="chkbxDietNutritionAgree" type="checkbox" />
</td>
<td align="left">
<p>I understand that diet and nutrition will affect my fitness goals and performance during boot camp.</p>
</td>
</tr>
<tr>
<td align="left">
<input id="chkbxPositiveAttitudeAgree" type="checkbox" />
