Member Application

MEMBERSHIP APPLICATION

Personal Information
Boxers Name*

First NameLast Name
Parent Guardian Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date Of Birth*

MonthDayYear
Date
Age
Citizenship (check one)

U.S. CitizenNaturalized CitizenPermanent Resident
Gender (Optional)
Have You Ever Completed Professionally
Have You Ever Competed in a USA Boxing Sanctioned Boxing Event

Release and Waiver
If consideration of membership is granted me or my son/daughter by United States Amateur Boxing Inc.,(USA Boxing) to participate in amateur boxing during my or his/her tenure as an amateur boxer, I, the undersigned, waive and release any and all rights that I, my heirs, executors, administrators, or assignees for all personal injuries, known or unknown, and injuries to property, real or personal, caused by or arising out of the above described sports activities.
If I observe any unusual, significant rule violations or hazards during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
I, the undersigned, fully understand and appreciate that participation in sports activities carries a risk to me or serious injury, including permanent paralysis or death. I voluntarily and knowingly recognize, accept, and assume the risk.
I, the undersigned, have read this Release/Waiver and understand all its terms and conditions. I execute it voluntarily and with full knowledge of its significance.
I, understand in consideration for membership with Jack Costello Boxing Club, I hereby permit and authorize Jack Costello Boxing Club, and its employees, agents and representatives who are acting on behalf of Jack Costello Boxing Club to use my likeness and/or name in any photograph, image, video, motion picture, performance or sound recording for purposes related to its mission including advertising, publicizing or marketing its gym and programs or for any other commercial or lawful purpose, and to use and license others to use it for such purposes, without any compensation to me.

I, understand that the "Boxer" named in the above application will follow all rules posted within the code of conduct located in the gym. Failure to do so can/will result in immedietate revocation of membship with no refund.
Signature*

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Female Boxers Only

Please Read and Sign Below
I certify that I am not pregnant or have any painful pelvic discomfort such as systematic endometriosis or other causes, abnormal vaginal bleeding of undetermined causes (etiology), recent loss of menstrual period (secondary amenorrhea), recently developed breast mass, resent breast dysfunction previously not present or surgical breast implants, and have read section 101.9 (4) of USABoxing's official rules pertaining to my present physical condition. I further agree that i will immediately notify my coach/club official if any of the above described conditions develop/apply.
Signature

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Memberships*

Youth Junior Boxing Membership RegistrationTuition Free Ages 9-12 Tues & Thurs 5pm-6pm $50 Registration includes Gloves, Handwraps, Mouth Guard

$50.00 for the first payment then,$ Free for each month

Youth Teen Boxing MembershipTuition Free Ages 13-19 Tues & Thurs 6pm-7pm $50 Registration includes Gloves, Handwraps, Mouth Guard

$50.00 for the first payment then,$ Free for each month

Adult RegistrationBasic Membership Tuesday & Thursday 7:30 PM - 9:30 PM Handwraps Included

$50.00 for the first payment then,$25.00 for each month

Cash PaymentMUST BE PAID BEFORE BEING ELIGIBLE FOR THE WAITING LIST.Must be completed in gym and approved before membership starts.

$ Free for each month

Subtotal

$0.00

Tax

$0.00

Credit Card

I understand that membership is not guaranteed and is pending approval based on availability. I agree to being placed on a waiting list for no more than 60 days if necesary.*
Should be Empty:

MEMBERSHIP APPLICATION

Release and Waiver

Female Boxers Only

Credit Card