Fight for Change Registration Form

Thank you for registering your child with Fight for Change, Inc. We are a nonprofit organization aimed at providing support and guidance for at-risk youth in the Midlands. Our goal is to help instill discipline, confidence, independence, and self-awareness, and promote healthy life choices. Fight for Change is also a Christian-based organization, and we believe that spiritual guidance is vital to the development of our youth.

We would love to see your youth a part of something that could change their lives forever. They are the key to our future and with strong, disciplined lives, the sky's the limit.

Feel fre to stay or come back an hour or so later to pick them up.

Please park on either side of the building, and not in front.

Fight for Change trains male and female adolescents aged 11-17. Each child must have a registration form filled out before training.

You do not need to schedule a time because our coaches are always available between the specified times above. If we are closed, it will be posted on our website. We do close for every federal holiday.

Your youth must come prepared to work out. This means shorts, t-shirt, and sneakers. Please no slides, crocs, or flip flops. Females can wear spandex but we do ask that they not wear sports bras. Tank tops over a sports bra is fine. Males are asked not to wear compression shorts as bottoms, but can wear shorts over them.

PLEASE BRING A BOTTLE OF WATER. We have an area to refill water. Please make sure they have eaten. We will not coax any child into working out. If they express that they do not want to train or have a tantrum, they will be sent home.

We are excited to train, develop, and support your youth and see the change that comes from being part of Fight for Change!!

Participant's Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

Parent's Name

First NameLast Name

Parent's Phone Number*

Parent's E-mail*

example@example.com

MEDICAL HISTORY

Have you had any family history of chronic disease (heart disease, diabetes, etc.)?*

If yes, please list

Have you ever been diagnosed or treated for any chronic disease including asthma?*

If yes, please list

Are you currently taking any medication?*

If yes, please list

Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?*

If yes, please list

PERSONAL DETAILS

If you have answered YES to any of the above questions, you must obtain a

medical clearance prior to carrying out a physical exercise program.

HEALTH RELATED BEHAVIOURS

Do you smoke?*

If yes, how many a day?

Do you drink alcohol regularly?*

If yes, how much per week?

How many times on average do you eat fast food per week?*

How many hours of sleep do you normally get per night?*

PSYCHOLOGICAL

Please rate the following. One star being negative to five stars being positive

I have a positive attitude towards things

I am always stressed out.

I am in the best shape of my life.

I would rate my current health.

I am serious about acheiving my goals

GOALS

Do you have any health related goals (i.e. Lower blood pressure, etc)?*

If yes, please list

Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?*

If yes, please list

Do you have any performance specic goals (i.e. Increase 10km run, increase chest strength, etc.)?*

If yes, please list

Do you wish to achieve any of these goals in a specific time frame?*

If yes, please explain

Who referred you to Fight for Change, Inc.?*

LIABILITY WAIVER

Please read carefully before submitting form.

I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Fight for Change, Inc.

Having such knowledge, I hereby release Fight for Change and its affiliate, Battle Boxing Gym of their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.

Please tick box in agreement to the above liability waiver*

I Agree

Signature