Burnout Boxing: Gold & Dual Member Joining Form

Date

Name*

First NameLast Name

Date Of Birth

Date

Gender*

Mobile Phone Number*

Mobile Number*

Email*

example@example.com

Emergency Contact*

First NameLast Name

Emergency Contact Mobile Number*

Where did you hear about us?

If selected 'other', please could you specify?

Gold Membership No.of the member who has referred you:

(this should start with BBG)

T-Shirt Size

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?*

YesNo

2. Do you feel pain in your chest when you do physical activity?*

YesNo

3. In the past month, have you had chest pain when you were not doing physical activity?*

YesNo

4. Do you lose your balance because of dizziness or do you ever lose consciousness?*

YesNo

5. Do you have a bone or joint problem (for example, Back, Knee or Hip) that could be made worse by a change in physical activity?*

YesNo

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

YesNo

7. Do you know any other reason why you should not do physical activity?*

YesNo

8. Is there anything else about your general health that we should know?

I hereby agree to the following:

In Consideration of being allowed to participate in the activities and programs of the Burnout Boxing bootcamps and to use the facilities and equipment owned and/or under the control of Burnout Boxing. I do hereby waive, release and forever discharge Burnout Boxing from any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities in the above mentioned activities.

I am aware that I have the right to request advice from any of the trainers at Burnout Boxing, at any time, in relation to the activities and exercise being undertaken and, but not exclusively, their suitability for me, with regards to my health and clothing. If i choose not to take advice, or to disregard any advice so given, I do so voluntarily and accept liability for all resulting injuries or damage.

I understand and i am aware that strength, flexibility and aerobic exercise, including the use of equipment, in the indoors are potentially hazardous activities. I also understand that exercise and fitness activities involve a risk of injury and even death. I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I hereby agree to expressly assume and accept all and any risks of injury or death.

I do hereby declare myself to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness that would prevent my participation or use of equipment or facilities except as herein stated. I acknowledge that i have either had a physical examination and have been given my doctors permission to participate, or that i have decided to participate in activity and use of equipment and machinery without the approval of my doctor and do hereby assume all responsibility for my participation and activities, and utilisation of equipment and machinery in my activities.

I understand and am aware that photo/video footage may be taken during boot camps. I give full rights for Burnout Boxing to use the images resulting from the photography/ video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group's aims. I also give them the right to use them in their printed and online publicity, social media and press releases.

I have read all the above information and fully agree to the terms and conditions stated.

Date*

Date

My Products

Maximum Fitness Gold Member Upgrade to Burnout Boxing (£80.00 for each month)

FOR CURRENT MAXIMUM FITNESS MEMBERS 12 month term

Dual Membership Burnout Boxing And Maximum Fitness (£140.00 for each month)

FOR NEW MEMBERS - 12 month term

Enter coupon

Total £0.00

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Medical (PAR-Q)