CPA Boxing Client Assessment Form

BASIC INFORMATION

Child’s Name

First NameLast Name

Child’s Birth Date

mm/dd/yyyy

Child’s age

Child’s school name

Child’s address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian name

First NameLast Name

Parent/Guardian Phone Number

Area CodePhone Number

Parent/Guardian E-mail

Emergency contact name

First NameLast Name

Emergency contact phone number

Area CodePhone Number

TRANSPORTATION

Do you need transportation?

YesNo

MEDICAL HISTORY

Does the child listed above have any family history of chronic disease (heart disease, diabetes, etc.)?

YesNo

If yes, please list

Does the child listed above have any allergies?

YesNo

If yes, please list

Has the child listed above been diagnosed or treated for any chronic disease including asthma?

YesNo

If yes, please list

Is the child listed above currently taking any medication?

YesNo

If yes, please list

Are there any other conditions related to the child listed above that we need to be aware of (i.e. Past or present injuries, etc)?

YesNo

If yes, please list

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.

LIABILITY WAIVER

Please read carefully before signing form.

I agree, the child listed above is in good health and I consider him/her capable of the activities taking place at Commander Peace Academy Boxing Club.

I agree, being aware of my child's health and physical condition, and having knowledge that their participation in any exercise program may be injurious to their health, they are voluntarily participating in physical activity with Commander Peace Academy Boxing Club.

Having such knowledge, I hereby release Commander Peace Academy Boxing Club, their representatives, agents, and successors from liability for accidental injury or illness, which my child may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to my child's participation in said program. In the event of an accident, I consent to any necessary medical treatment. In an emergency, I consent to treatment by medical health professionals, if considered necessary.

I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my child's ability to participate in the Commander Peace Academy Boxing Club's program.

Please sign and date below in agreement to the above liability waiver

Date

mm-dd-yyyy