Fight

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Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Next of Kin Name*

Next of Kin Contact Number*

Doctor Name*

Doctor Surgery / Contact*

Do you suffer / Have you suffered from any of the following?

Rheumatoid or Osteo Arthritis
Head / Neck Injury
Shoulder/Arm/Wrist/Hand Injury
Back Pain / Injury
Hip / Pelvis Injury

Do you suffer / Have you suffered from any of the following?

Knee / Thigh / Leg Injury
Ankle / Foot Injury
Nerve Damage
Swollen Joints
Fractured Bones
TBI – Traumatic Brain Injury

Do you suffer / Have you suffered from any of the following?

If You answered yes above, please provide details

Are you currently recieving treatment for anything?

Yes
No

Have you had major surgery in the last 10 years?

Yes
No

Have you had minor surgery in the last 2 years?

Yes
No

If you answered yes to the above, please provide details

Do you suffer / have you suffered OR have you ever had a medical consultation for any of the following conditions?

If You answered yes above, please provide details

Any other health issues not already mentioned, please list here:

Are you pregnant?

Yes
No

Have you ever been diagnosed with a learning disability / have any problems learning in school / require any special provision for assessments because of learning issues?*

Yes
No

I confirm that I am a UK Resident.*

Yes

Please select the date of the event:*

Please select your employment class:*

Please pick the option below that matches your occupation best.

I understand that I will be participating in an Unlicensed White Collar Boxing Match*

Yes

Unlicensed meaning not affiliated to a boxing organisation.

I understand that all elements of the event will be physically demanding. I accept full & complete responsibility for my participation in this practical event.*

Yes

I agree that Shipston Personal Training LTD, Marc Edwards & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by my participation*

Yes

I agree that Shipston Personal Training LTD, Marc Edwards & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by this training with 3rd parties*

Yes

I understand that by signing this / completing this form that I assume all responsibility for myself and if I share this knowledge with a third party, the safety of the end user*

Yes

Shipston Personal Training LTD, Marc Edwards and Representatives means anybody delivering a training session / Course / Workshop in association with / on behalf of Marc Edwards or Associated Training Provider.

I am aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, I am voluntarily participating in a physical activity.

Having such knowledge, I hereby acknowledge this release, any representatives, agents and successors from liability for accidental injury or illness which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

I’m aware that the insurance provided will cover me for personal accidents and I accept all risks and responsibilities of entering into a contest that involves boxing. I’m aware that the insurance does not cover me for injury sustained by another or to another individual.

I’m aware that there may not be a medical supervisor at the event, including but not limited to a Doctor or Paramedic and I still choose to participate.

Please type full name as signature:*

Demands and Needs statement The Sports Accident Insurance policy meets the demands and needs of an active person who wishes to be covered by a Sports Accident policy whilst participating in sports/leisure activities that are named within the Sports Group(s) chosen, for the duration specified, and for the level of benefits requested. It is in no way a substitute for Travel Insurance, and should not be relied upon to cover Medical Expenses abroad, or Repatriation. .

Policy Wording

Terms & Conditions

What will be insured

PTSOS Fight Registration