Boxing Registration Form

Different Breed Boxing

Boxing Registration

640 GA-138, Riverdale, GA 30274

Participant's Information

Participant's Name*

First NameLast Name

Are you over 18 ?*

YesNo

Age*

Participant's /Legal Guardian Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Cell Phone*

Area CodePhone Number

E-mail*

Boxing skill level*

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Interested in Competing?*

YesNo

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. )

Important Notes · Dress appropriately. No food or drink in the gym ( only water ). · Keep the gym clean. The league organizers (Coaches) reserve the right to ensure the talents of all participants by categorizing in proper weight class to balance teams. Fee: $50 (one time charge) per child and $100 monthly charge per child· Boxing gloves and hand wraps will be provided.

Hours of Operation

Monday : 6pm -8pm

Tuesday : Closed

Wednesday : 6pm -8pm

Thursday : Closed

Friday : 6pm -8pm

Saturday : Closed

Emergency Contact

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

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

YesNo

Please describe*

Parental Permission For Emergency Treatment In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to: I give consent for the facility to secure any and all necessary emergency medical care for my child.

Name of Physician / Emergency Medical Care Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Who is your insurance provider? Provide Insurance card number if applicable.

Release of Liability Although the safety of all sport activities is the primary concern, indoor sport activities at Different Breed Boxing may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against Different Breed Boxing and the persons in charge.

Confirmation E-mail*

I have read and agree to the above conditions*

YesNo

Signature*

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at differentbreedboxing1@gmail.com 513-930-8939

My Products

Registration and Monthly charge$150.00

One time fee of $50 (registration fee) + Monthly charge of $100.

Quantity

Total $0.00

Payment Methods

Choose from one of the PayPal options to make your payment.