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Boxing Registration Form

A registration form for boxing classes that gathers participant details, insurance information, emergency contacts, and acceptance of program terms.

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Boxing Class Registration

Please complete all fields below

Participant's Name*

Nombre

Apellido

Are you over 18 ?*

Yes No

Participant's /Legal Guardian Name*

Nombre

Apellido

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Home Phone*

Cell Phone

E-mail*

Boxing skill level*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Interested in Competiting?

Yes, I'm interested in competing

List below the following reasons you decided to join this boxing program? (Examples : Strengthening upper- body and core. Boosts endurance. Improving hand-eye coordination, competing, confidence etc. )

Emergency Contact

Please provide someone we can reach in case of an emergency

Emergency Contact's Name*

Nombre

Apellido

Relationship*

Phone Number*

Do you have health insurance ?

Yes No

Insurance Carrier

Name of Policy Holder

Subscriber ID/Group Number

Card Number / Card Date

Does you have any allergies, breathing conditions , or medical conditions that would limit high level activtiy?*

Yes No

Please describe*

Physician Information

Name of Physician / Emergency Medical Care Facility

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Waiver Agreement

I have read and agree to the above conditions*

I Agree I Disagree

Confirmation E-mail*

Signature*

Sign here

Thank you for registering

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