Phoenix Outreach - Disclaimer
Please complete before attending your 1st session.
Declaration
I the student / parent / guardian, agree that whilst training without insurance student / parent / guardian understands that no liability what so ever is attached to Richard Lewis, Rachael Reid, Phoenix Outreach, Phoenix Muay Thai Ltd or any of its instructors for any accident causing injury, damage or death to any person or persons, or property that may arise whilst attending any activities otherwise within or about the premise. The student has no known medical illness, disability or takes any medication, which prohibits or impedes them from participating in the activities and functions of the club that has not been declared below.
Name
First Name
Last Name
Name of parent / guardian / carer (if under 16)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of birth
*
-
Day
-
Month
Year
Date
Ethnic Origin
Gender
Next of Kin - Full Name
*
Next of Kin - Phone Number
*
-
Area Code
Phone Number
Next of Kin - Relationship to you
*
Relevant Medical Information
*
Include any disabilities, allergies, medication, past serious illnesses and / or injuries
Occupation
Are you a student?
Yes
No
How did you hear about the project?
Photo Consent - At times the Phoenix Outreach team members may wish to take photos or videos of individuals and the club as a whole. These will solely be used for the purpose they are intended for, which is the promotion and celebration of the project for training purposes. These images may appear in printed publications, video and on the Internet i.e. Facebook, Instagram, twitter, Tumblr, flicker via the club’s websites
Yes
No
Keeping In Touch - From time to time, we would like to send you communication regarding lessons, events and projects that are taking place with Phoenix Outreach, we will never pass you details on to third parties. Please tick the boxes below to tell us all the ways you would prefer to hear from us:
Yes please, I would like to receive communications by email
Yes please, I would like to receive communication by telephone
Yes please, I would like to receive communication by mobile (text message)
No thank you, I do not wish to receive communication
Signature of applicant
Signature of parent / guardian /carer (if under 16)
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