Roxboro Youth Boxing

Roxboro Youth Boxing

Registration Packet
Athlete Information
Athlete's Name*

First NameLast Name
Guardian / Parents Names*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone
E-mail*
example@example.com
Athlete's Date of Birth*

MonthDayYear
Date
How would you describe the athlete's boxing skill level?*

1

2

3

4

5

1 is Beginner, 5 is Advanced
Emergency Contact & Health Insurance Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Does you have any allergies, chronic illness, or medical conditions that would limit high level activity?*

YesNo
Please describe your limitations. (Write "N/A" if this does not apply.)*
Have you completed and submitted a recent Physical Form to Roxboro Youth Boxing?*

YesNo
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
Release of Liability

Although the safety of all sports activities is the primary concern, indoor sports activities at BOXING GYM 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 BOXING GYM and the persons in charge.
The RYB Expectations:

· Athletes are expected to dress appropriately for each session.

· No food or drink in the gym unless approved by coaches and facility members.

· Appropriate headgear and mouthpieces must be worn during sparring.

· Athletes are expected to respect the facility and RYB staff at all times.
I have read and agree to the above conditions*

YesNo
Signature*

Clear
Should be Empty:

Roxboro Youth Boxing

Release of Liability