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More Information About the Women's Weekend Welltrust Women's Health Weekend Schedule
 
 

REGISTER FOR WOMEN'S HEALTH WEEKEND 2010

April 16-18, 2010 at Camp Taiwan Outdoor Adventure Learning Center

The Welltrust Women’s Health Weekend is brought to you by Welltrust Health Solutions, Bodyworks Fitness &Camp Taiwan.

CONTACT INFORMATION
Phone No.
Cell Phone No. E-mail
    Would like to room with:
       
HEALTH INFORMATION    
The health and medical information on this form is confidential and is used only to ensure the health and well-being of the participant.
       
Food Restrictions:    
Does not eat:
Other
 
     
    If yes, describe, explain or list
1. Have a recent injury or illness Yes No
2. Have a chronic or recurring illness/condition Yes No
3. Have been hospitalized in the past 3 months. Yes No
4. Are under a Doctor’s care for illness or injury Yes No
5. Have frequent headaches Yes No
6. Ever had a head injury Yes No
7. Ever been knocked unconscious Yes No
8. Ever been dizzy or fainted during exercise Yes No
9. Ever had seizures Yes No
10.Ever experienced chest pain during or after exercise
 Yes No
11. Ever had high blood pressure Yes No
12. Ever been diagnosed with heart murmur Yes No
13. Ever had back problems Yes No
14. Ever had joint problems (knee, ankle, etc) Yes No
15. Have diabetes Yes No
16. Have asthma Yes No
17. Have allergies to food or medication Yes No
18. Am presently taking medication Yes No
     
ACTIVITY LEVEL    
       
I  
I engage in yoga or tai-chi times per week.  
I am in good health, do not have a regular fitness program/regime and am not interested in one.
I am in good overall health and want to improve my overall level of fitness.
       
       
PAYMENT    

NT$10,000 Includes: Two night stay in our safari tents including linens and towels, all activities, equipment, instruction, speakers, snacks and 6 meals.

E-mail Confirmation: After you register for the Welltrust Women's Health Weekend, you will be e-mailed registration confirmation and instructions for arranging for payment.
       
SIGNATURE    

I, the undersigned, understand and acknowledge that certain camp activities, whether or not listed in promotional materials, which include but are not limited to horseback riding, ropes course, climbing etc. have an increased risk of injury associated with them. I have listed above all medical information about myself. I herby release and agree to indemnify and hold harmless, Camp Taiwan and all its officers, directors, employees, agents and representatives whatsoever from any and all losses, claims, damages, liabilities, costs and expenses including attorney fees, which they or any of them, or camper may sustain or incur in any way arising out of or in connection with my participation in any and all camp activities. I herby give permission to any physician selected by the camp director, to secure proper treatment, which may include hospitalization, if necessary.. I agree that Camp Taiwan is not responsible for the loss or damage of personal belongings by fire, theft, etc. I understand that Camp Taiwan recommends participants not bring expensive items such as watches, cameras, radios, walkmans etc. I understand that the Camp reserves the right to dismiss a participant whose conduct is dangerous, illegal or, at the discretion of the director feel is detrimental to the camp and/or to other participants – fees will not be returned in the event that participants are asked to leave. Photographs taken of you or your group may be used for promotional purposes.