Exit this survey Body Language Re-Boot Registration (2/25-4/5) Question Title * 1. Please complete the required information to save your spot and "pre-register" for "Re-Boot": Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Question Title * 2. Has a doctor ever said you have a heart condition? Yes No Other (please specify) Question Title * 3. Do you have chest pain brought on by physical activity? Yes No Other (please specify) Question Title * 4. Do you take blood pressure medicine? Yes No If yes, please describe Question Title * 5. Do you have a joint or bone problem? Yes No If yes, please describe any area(s) that apply: Question Title * 6. Have you consulted with your physician regarding increasing your physical activity? Yes No If yes, please note physician comment(s): Question Title * 7. Do you know of any other reason why you should NOT engage in physical activity? Yes No If yes, please explain: Question Title * 8. What is your main reason for participating in this fitness program? Question Title * 9. What are your goals and in what time frame? Question Title * 10. How did you hear about Boot Camp? Body Language Website (www.blfit.com) Body Language Email Distribution Facebook / Twitter Friend / Family Member Other (please specify) Done