Client information
This is an important document which affects your legal rights and obligations
Name
First Name
Middle Name
Last Name
Gender
Male
Female
N/A
Birth Date
Please select a month
January
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Month
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Day
Please select a year
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Year
Email
example@example.com
Mobile number
Fitness goals
Weight loss
Re-shaping/toning
Improve health
Increase energy
Improve self-esteem
Stress management
Group exercise
Personal training
Learn boxing technique
Boxing sparring
Cardio exercise only
Boxing competition
Other
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Health and wellbeing
Has there been any significant change to your health in the last 6 months
No
Yes - please comment below
Comments
Please tick conditions which apply - if ticking a box, please supply additional information below.
Back pain
Heart problem
Fainting/dizziness
Heat stress
Asthma
Diabetes
Epilepsy
Pregnancy
Mental illness
Please supply additional information here
Are you under the care of a physiotherapist/general practitioner or other allied health professional? Please detail here:
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Acknowledgement, Release and Assumption of Risk
I acknowledge that the activities that I am to undertake have potential dangers and by participating in them I am exposed to certain risks. I acknowledge and understand that whilst participating in any such activities:
I may be injured, physically or mentally, or may die as a result of the activity and I assume full risk and responsibility for any injury, death or property damage resulting from my participation in the activity.
My personal property may be lost or damaged.
Any physical conditions I may have, or which I may or may not be aware of or have disclosed to the gym or their staff, may be aggravated or worsened by my participation.
Other persons participating in such activity may cause me injury or may damage my property.
I may cause injury to other persons or damage their property.
The conditions in which the activity is conducted may vary without warning.
I agree to my image or the image of the young person named in this document being published by managment on any social media platforms for promotional purposes.
Where the participant is under 18 years of age I consent to the young person named in this Acknowledgement and Release participating in the activity and I am aware of the risks, dangers and obligations set out above and release Bobby Dunne's Boxing & Fitness Gym operators or its servants and agents in respect of injury, death, loss or damage.
Before signing this document I have read and understood it and know how it affects my legal rights. I have read and understood all the terms and conditions listed in this form and my signature below confirms my agreement with all of them.
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