Adaptive Boxing – Sign-Up Form
1. Full Name
First Name
Last Name
2. Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
3. Email Address
example@example.com
4. Phone Number
Format: 00000 000000.
5. Emergency Contact – Name & Number
Boxing Background
6. Have you boxed before?
Yes – regularly
Yes – a little
No, completely new to boxing
7. Do you currently train at a boxing club?
Yes
No
If yes: Which club?
Adaptive Boxing
8. Please briefly tell us about your impairment/disability.
9. Are there any physical movements that you may find difficult?
10. Is there anything you need us to adapt or consider during your sessions?
Back
Next
Goals
12. What are you hoping to get from adaptive boxing?
Fitness & training
Learn boxing
Social/community
Potential competition
Exhibition boxing
Other
13. What would you like to achieve through your boxing?
Before Your First Session
14. Is there anything else you think our coaches should know before your first 1:1 session?
15. Are you local to Sussex? If not are you happy to do online sessions?
16. How did you hear about us?
Social media
Boxing club
Friend/family
WBC Cares
Referral
Other
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