Neftaly Registration Form Template

Objective: To collect essential participant information and confirm their enrollment in the Neftaly Health and Wellness Camp.

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Participant Information

1. Full Name:
2. Date of Birth:
3. Gender:
   • Male
   • Female
   • Non-Binary
   • Prefer not to answer
   • Other: _______________________
4. Email Address:
5. Phone Number:
6. Home Address:

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Emergency Contact Information

7. Emergency Contact Name:
8. Emergency Contact Phone Number:
9. Relationship to Participant:

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Health and Wellness Information

10. Do you have any dietary restrictions or food allergies?
    • Yes (please specify): __________________________________________________
    • No
11. Do you have any current medical conditions or health concerns that we should be aware of?
    • Yes (please specify): __________________________________________________
    • No
12. Do you currently follow a fitness routine?
    • Yes
    • No
13. Are you currently taking any medication?
    • Yes (please specify): _____________________________________________
    • No
14. Please list any other relevant health or wellness information you’d like to share (optional):

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Camp Preferences

15. What are your primary goals for attending the camp? (Select all that apply)
    • Nutrition and meal planning
    • Fitness and exercise routines
    • Stress management and mindfulness
    • Weight management
    • Improve mental health
    • Build healthier habits
    • Other (please specify): __________________________________________
16. Do you have any specific expectations or requests for the camp?

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Agreement and Signature

17. Medical Waiver:
    I acknowledge that participation in physical activities may involve a risk of injury. I hereby release the Neftaly Health and Wellness Camp organizers, facilitators, and staff from any liability in the case of an accident, injury, or health-related incident during the camp.
    • I agree to the terms and conditions.
18. Photo/Video Release:
    I consent to the use of photos, videos, and testimonials captured during the camp for promotional purposes.
    • I agree
    • I do not agree

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Signature:

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Date:

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Payment Information (if applicable)

19. Payment Method:
    • Credit Card
    • Debit Card
    • Bank Transfer
    • Other (please specify): _______________________________
20. Payment Amount:

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Thank you for completing the Neftaly Registration Form! Your information will help us ensure a smooth and personalized experience at the camp. We look forward to having you with us!