Your Name (required)
Gender (required) MaleFemale
Date of Birth (required)
Age (required)
Title (required) Mr.Mrs.Ms.MissOther
Address (required)
City (required)
Telephone
Mobile (required)
Home
Email (required)
In case of Emergency:
Name (required)
GP Surgery
Name of Doctor
Contact Number
Type of Membership (required) Full CorporateOff PeakConcessionFree Project
If you are a registered member, please enter your username
Physical Activity Questionnaire – To be completed by parent or guardian if under 18
PLEASE READ THE QUESTIONS CAREFULLY AND ANSWER TRUTHFULLY AND ACCURATELY BY TICKING YES/NO
Has your doctor ever said that you have a heart condition? YesNo
Have you recently had chest pains bought on by exercise? YesNo
Are you currently receiving treatment/ medication for high blood pressure? YesNo
Do you have bone or joint problems that could be aggravated by exercise? YesNo
Do you often feel faint or have dizzy spells? YesNo
Do you suffer from epilepsy or chronic asthma? YesNo
Is there any possibility that you may be pregnant or given birth in the last 6 months? (Miscarriage, pregnancy, fertility problems)? YesNo
Are you diabetic Type I or Type II? I am not diabeticDiabetes Type IDiabetes Type II
Have you undergone surgery in the last six months? YesNo
Are you over the age of 65 and not accustomed to vigorous exercise? YesNo
Is there any reason not mentioned above that would stop you taking part in an exercise programme or boxing training? YesNo
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? (If Yes, Please specify) YesNo Please Specify:
As far as you are aware, are you allergic to any drugs or medication? Please state: YesNo Please Specify:
Are you taking any regular medication? If yes, Please state: YesNo Please Specify:
Do you have any long term injuries or illnesses? If yes, please state: YesNo Please Specify:
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? YesNoPrefer 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 sayOthers (Please Specify) 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.
ETHNICITY OF CLUB MEMBERS —Please choose an option—White BritishWhite IrishWhite OtherMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – OtherAsian or Asian British - IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – OtherBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – OtherAsian or Asian British - ChineseAsian or Asian British - AfghanistaniEastern EuropeanOther Ethnic Group
How did you hear about us? —Please choose an option—Member ReferralWord of mouthAdvertisementPromotionOther
Can we contact you by phonecall or text regarding our projects, service and events? YesNo
Can we contact you by email regarding our projects, service and events? YesNo
Can we contact you by WhatsApp regarding our projects, service and events? YesNo
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
Sign
Are you a guardian? YesNo
Send
Stonebridge Boxing Club is a registered charity in England and Wales (No.1136707). Affiliates: England Boxing | Team Sauerland | Blackstone Sports Management
Monday – Friday: 11:00 am – 10:00 pm
Saturday: 12:00 pm – 2:00 pm
Sunday: 10:00 am – 12:00 pm