Sign-up for a Bootcamp Republic Program

Step 1
Select your program(s) and enter your personal information
Step 2
Review and Confirm Order
Step 3
Pay Securely
All fields are required. No refunds.

Select Your Program(s)

Fitness Bootcamp

$250
Full Session: Full 3-week scheduled session of Bootcamp
$175
Full Session: Full 3-week scheduled session of Bootcamp [Student Discount]
Only valid if you are currently a student and can provide proof with a tuition receipt.
Partial Sessions: Only available if you have spoken to or emailed our staff (646.460.6787 or admin@bootcamprepublic.com)
and have received special permission to join in the interim of a Bootcamp Republic session.
Do not register for a bootcamp


Select bootcamp location and date:


Healthy Republic: Nutrition

$75
Nutrition Bootcamp: 2-week program
Double the effectiveness of bootcamp. Enroll to participate in two 45-minute webinars given by our Nutrition Consultant and get answers to your specific questions.
Select the date:

$150
Personal Nutrition Coaching: 3-week program
Have your very own personal Nutrition Consultant help you reach your goals. Your enrollment includes: both webinars in the Nutrition Bootcamp Program, one-on-one counseling via email or phone, analysis of your food intake, a personalized eating regiment, and help with breaking old habits and implementing permanent changes.
Select the date:

Do not register for nutrition. I'm at my ideal weight and/or I'm satisfied with my current eating habits.

Total

Promotion Code

If you are redeeming an exclusive Bootcamp Republic offer, please enter the Special Code:  
Important: This offer will be applied in Step 2: Confirmation before checkout.

Contact Information
First Name
MOBILE CELL phone number
  
Required: A text message is sent to your mobile phone for camp cancellations due to weather.
 
Last Name
Sex
 Male Female
Address
Date of Birth (MM/DD/YYYY)
City
Email Address
State
Emergency Contact Name
Zip Code
Emergency Contact Number

Health Information
Before Bootcamp, I would describe the level at which I exercise to be:

Never
Not for a long time
Infrequent or event driven
 Regularly 1x per week
Regularly 2-3x per week
Regularly more than 3x per week


Please list any health problems, health risks, or injuries that could affect you during exercise. (e.g. asthma, allergies, ACL knee injury, high blood pressure, high cholesterol, diabetic Type I or Type II, pre-diabetic risk, etc.)


Check here if this does not apply to you
Your height: feet    inches        Your weight: lbs.
What are your Fitness Goals at Bootcamp? Please check all that apply.

Lose 5 lbs.
Lose 10 to 15 lbs.
Lose 20 lbs. or more
Increase my energy level
Reduce an existing health problem
Prevent a health risk or genetic health risk
Strengthen body from an injury
Increase metabolism
 Fight depression
Increase endurance/stamina
Tone up/strengthen
Jump-start my usual workout routine
Start bootcamp as my regular workout
Train for an athletic event
Generally feel better


Bootcamp Republic and You
Are you a repeat client?

 Yes   No
How did you hear about us?