Registration Form

Bridgnorth Boxing Academy Registration Form & PARQ
Full name

First NameLast Name
Parents Name (U16)

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate Of Birth
Address

Street Address

Street Address Line 2

TownCounty

Postcode
E-mail
Phone Number
Emergency contact

First NameLast Name
Phone Number
Health questionnaire (Par-Q)
This questionnaire does not provide advice. Nor should it substitute for advice from an appropriately qualified medical professional.

The use of this pre screening questionnaire in no way guarantees or safeguards against any injury or death sustained as a consequence of undertaking activities.

No responsibility or liability whatsoever can be accepted by Bridgnorth Boxing Academy for any loss, damage, illness, injury or death that may arise from any person acting on any statement or information contained in this document.

Par-Q

Rows	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: