Gender* Male Female
Date of Birth*
Age*
Title* Mr. Mrs. Ms. Miss Other
Telephone
In case of Emergency:
GP Surgery
Type of Membership* Full Corporate Off Peak Concession Free Project
Physical Activity Questionnaire – To be completed by parent or guardian if under 18
PLEASE READ THE QUESTIONS CAREFULLY AND ANSWER TRUTHFULLY AND ACCURATELY BY SELECTING YES/NO
Has your doctor ever said that you have a heart condition?* Yes No Yes No
Are you currently receiving treatment/ medication for high blood pressure?* Yes No
Do you have bone or joint problems that could be aggravated by exercise?* Yes No Yes No
Do you suffer from epilepsy or chronic asthma?* Yes No Yes No I am not diabetic Diabetes Type I Diabetes Type II
Have you undergone surgery in the last six months?* Yes No Yes No
Is there any reason not mentioned above that would stop you taking part in an exercise programme or boxing training?* Yes No
Junior Membership Only: Are there any other medical conditions that are not on this list that may affect your Child’s ability to train with the boxing club?
Yes No
As far as you are aware, are you allergic to any drugs or medication?* Yes No
Are you taking any regular medication?*
Yes No
Do you have any long term injuries or illnesses?*
Yes No
I confirm that the answers are correct at today’s date, to the best of my knowledge and belief. I undertake to notify staff at once if at any future dates any of the above answers change. I agree not to use any of the exercise equipment without receiving a full induction beforehand in its use from a member of staff.
If you answer yes to question 3 and/ or more questions you will need to bring a letter from your doctor stating you are fit to take part.
Do you consider yourself to have a disability?* Yes No Prefer not to say
If you have a disability, please indicate which reflects your disability: Hearing (deaf, partially deaf or hard of hearing) Learning disability (dyslexia, autism) Mental Health (depression, schizophrenia) Long term illness (cancer, HIV, multiple sclerosis, diabetes) Vision (blind or partially sighted) Physical Impairment (using wheelchair, difficulty using arms) Speech (speech impairment causing communication problems) Prefer not to say Others (Please Specify)
Declaration: I consider myself or my son/ daughter to be physically fit and capable of full participation and agree to notify the club of any changes to the medical information provided. I also state that I wish to participate in all boxing training activities that may include aerobic exercise, resistance exercise, stretching, and sparring. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in activities at the club. Furthermore, in the event that I am injured (or my son/daughter), I give my permission for the team managers/ coaches appointed by Stonebridge Boxing Club to obtain emergency medical treatment on my behalf.I agree that my basic details be shared with funders. --- White British White Irish White Other Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Mixed – Other Asian or Asian British - Indian Asian or Asian British – Pakistani Asian or Asian British – Bangladeshi Asian or Asian British – Other Black or Black British – Caribbean Black or Black British – African Black or Black British – Other Asian or Asian British - Chinese Asian or Asian British - Afghanistani Eastern European Other Ethnic Group
How did you hear about us?*
--- Member Referral Word of mouth Advertisement Promotion Other
Can we contact you by phonecall or text regarding our projects, service and events?* Yes No
Can we contact you by email regarding our projects, service and events?* Yes No
Can we contact you by WhatsApp regarding our projects, service and events?* Yes No
PHOTOGRAPHY/ FILMING/ AUDIO: I am aware that there maybe times that photographs, footage or audio taken during training sessions by approved agents and/or officers of Stonebridge Boxing Club which shall only be used for publicity/training purposes in accordance with the SBC Safeguarding and Child Protection Policy and give consent for myself or son/ daughter to feature in them.
Date of Signing:*
Signature:*
Are you a guardian?* Yes No
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