Senior Membership Form

We are very pleased to welcome you to the

Greenbank Boxing

Club.
To ensure we have the correct contact details for you, please fill out this form and return it to one of your club coaches or club committee members. If you are under 18 your parent or carer must sign this form before it is returned. We will also use this information to ensure that you are kept informed about club events.

Personal Details
Name: Date of Birth: Gender: Address: Suburb: Home Phone: Email: Postcode: Mobile:

Boxing information
Have you boxed before? If yes, where have you boxed:
(School, Youth Club. Boxing Club, Other - including Kick Boxing)

Yes

No (go to next section)

Emergency contact details:

Name: Address: Relationship: Home Phone: Name: Address: Relationship: Home Phone:

(Please supply details of two emergency contacts)

Mobile:

Mobile:

720-768 Middle Rd, Greenbank QLD 4124 Postal Address: 27 Graceland Dr, North Maclean Qld 4280 Mobile: 0410690872 ABN: 41618074467

Health Care Details

Medicare Number: Private Health Insurance Yes No

Current Medical History

Current Medical Issues: Regular Medications: Allergies: Sports Injuries:

Past Medical History

Do you wear:
Glasses Contact Lenses Soft Contact Lenses Hard Yes Yes Yes No No No

Have you sustained:

A fracture in the last 3 years
If yes, where?

Yes

No

A dislocation
If yes, where?

Yes

No

Do you suffer from:

Recurring pain in any join with play/practice?
If yes, where?

Yes

No

Back / Neck pain Have you even been treated for a head, neck or spinal injury?
If yes, provide details?

Yes Yes

No No

Does his condition affect your performance?

Yes

No

720-768 Middle Rd, Greenbank QLD 4124 Postal Address: 27 Graceland Dr, North Maclean Qld 4280 Mobile: 0410690872 ABN: 41618074467

Rules of Participation
1. All participants must complete and return the Greenbank Boxing Club Registration form before they will be permitted to commence training. 2. All participants (or parent/carer of participants under the age of 18) will sign on prior to commencement of each training session. 3. All participants will pay a fee of $5.00 prior to the commencement of each training session. 4. Only participants will enter training areas and only when under the supervision of a trainer or supervisor nominated by the trainer. 5. All participants will be respectful to all members at the boxing club at all times. Participants not conducting themselves in a suitable manner will be asked to terminate their training session and may be asked to leave the club. 6. All participants are to perform activities assigned to them at the time of the request any refusal to complete an activity will lead to the participant being asked to terminate the training session and may also lead to the participant being asked to leave the club. Boxing requires members to be focused dedicated and responsible to avoid unnecessary injuries. Trainers at this club take this sport seriously and expect all participants to do the same. All participants and parents of participants are to adhere to the abovementioned rules at all times and respect the decisions made by trainers and club representatives.

Consent:
I, ______________________________________________________________________________ have read the information contained within this form and hereby consent to taking part in boxing activity sessions and understand and agree I will participate in boxing sessions under the instruction of the coaches entirely at my own risk. I have considered the nature of such sessions and I am satisfied that I am sufficiently responsible and competent to assume responsibility for my under the supervision of the coaching staff. I confirm I do not have any medical disability or medical condition (not disclosed overleaf) that could affect my ability to participate safely in boxing sessions. By returning this completed form, I agree taking part in the activities of the club. I understand that I will be kept informed of these activities for example timings and transport details.

I have read and understand and agree to adhere to the Rules of Participation.

_______________________________________________________ Name of parent / carer: _______________________________________________________ Signature of parent / carer: _______________________________________________________ Date:

720-768 Middle Rd, Greenbank QLD 4124 Postal Address: 27 Graceland Dr, North Maclean Qld 4280 Mobile: 0410690872 ABN: 41618074467