Participants Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent/Guardian

If under 16yrs

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Structural Health

Does the participant suffer from any of the following conditions

Osteoarthritis

Rheumatoid Arthritis

Head / Neck Pain

Shoulder Injury

Arm / Elbow Injury

Wrist / Hand Injury

Back Pain / Injury

Hip / Pelvis Injury

Knee/Thigh/Leg Injury

Ankle/Foot Injury

Nerve Damage

Swollen Joints

Fractured Bones

If you answered yes please give details below.

Medical History

Is there a family history of, or have you ever had medical consultation for any of the following:

Epilepsy

Diabetes

Asthma

Cancer

Heart Problems

Chest Pains

Hypertension

Hypotension

Other

Disclaimer *

If you engage in this exercise or exercise program, do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge Calcot & Tilehurst Kickboxing and Parent Company South East Academy of Martial Arts from any and all claims or causes of action, known or unknown, arising out of negligence. NOTE: that with membership you will be provided with P2P insurance From time to time we may take group/individual photographs to use with Social Media. Unless otherwise advised we assume you are happy for us to use these, If you do not wish for these to be used, please tick the "opt out" option below

I am aware and agree that will take part in activities at my own risk*

I would not like photos to be used for social Media without further consent