Coach Breaux's Boxing Registration Form

Millington Boxing Academy

Introduction to Boxing Registration Form

4885 Bill Knight Road, Millington, TN 38053

Participant's Information

Child's Name #1*

First NameLast Name

Birth Date*

MonthDayYear

Participant's Legal Guardian Name #1*

First NameLast Name

Participant's Legal Guardian Name #2

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 Beginner, 5 is Advanced

Interested in Competiting?

YesNo

Important Notes · Dress appropriately and no open toes shoes. · 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. ·

Hours of Operation. Classes start Tuesday, March 25th. Please select the sessions you are interested in attending.

Tuesdays & Thursdays (2:30 - 3:45pm)Tuesdays & Thursdays (3:45 - 5:00pm)

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

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Do you have health insurance? *This does not disqualify you from participating.*

YesNo

Insurance Carrier

Name of Policy Holder

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 the nearest medical treatment facility. 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

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 Millington Boxing & Fitness.

Having such knowledge, I hereby release Millington Boxing Academy, Breaux Advisors LLC, their representatives, agents, and successors from liability for accidental injury or illness, which 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.

Signature

I have read and agree to the above conditions*

I agree