Boxing Registration Form

EJ's Boppin House

Boxing Registration Forms

35 Woodland St., New Britain, CT 06051

Contact

Ejsboppinhouse@gmail.com

(860) - 518 - 4913

Participant's Information

Participant's Name

First NameLast Name

Are you over 18 ?

Participant's /Legal Guardian Name

First NameLast Name

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail

Boxing skill level

	1	2	3	4	5

1 is Begginer, 5 is Advanced

Interested in Competiting?

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: $100 a month for adults $80 a month for childrern 17U·

Hours of Operation

Monday : 4-8pm

Tuesday : 4-8pm

Wednesday : 4-8pm

Thursday : 4-8pm

Friday : 4-8pm

Saturday : Closed

Sunday : Closed

Emergency Contact & Health Insurance Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Do you have health insurance ?

Insurance Carrier

Name of Policy Holder

Subscriver ID/Group Number

Card Number / Card Date

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

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

Release of Liability Although the safety of all sport activities is the primary concern, indoor sport activities at Ejs Boppin House facility 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 Ejs Boppin House and the persons in charge.

I have read and agree to the above conditions

Confirmation E-mail

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 Ejsboppinhouse@gmail.com.