Shipston Games Registration PTSOS Shipston Games Registration Name* First Last If you are now Team Captain of your, well, team…. How would you like to be known?CaptainEl CapitanDelBatmanChiefAll Powerful Supreme Sultan of (team name)BossI'm not the CaptainIf you’re not the team captain… How would you like to be known?RodneyRobinSidekickThe one who carries the captainComplimentary oppositeSilent killerNAAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date of Birth* DD slash MM slash YYYY 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 Do you suffer / Have you suffered from any of the following? Heart Problems Diabetes Epilepsy Early menopause Cancer If You answered yes above, please provide detailsAre 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 detailsDo you suffer / have you suffered OR have you ever had a medical consultation for any of the following conditions?AsthmaEpilepsyHigh / Low Blood PressureHeart Conditions / ProblemsChest PainsIf You answered yes above, please provide detailsAny 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:*Pairs: 22/03/2025Please Type the name of your team* Please provide the name of your team mate, partner or soul mate (as long as they can help you win!)* Please provide an email address for your team mate.* Carefully Enter the email address of your team. As the team captain, you’re solely responsible for getting your team sorted. We will issue them a copy of this waiver/registration form via email. NO WAIVER = NO COMPETE.Please select your employment class:*A – Desk Based Occupations / Student / Unemployed / RetiredB – Supervision of Manual Work, Light Manual WorkC – Travelling Sales, Manual Work, Tradesman, Self EmployedD – Drivers, Heavy Manual WorkPlease pick the option below that matches your occupation best.I understand that I will be participating in an open fitness competition and will provide my own insurance.* Yes Sports Cover Direct are preferred company. The event organisers will not be held liable for any injury you may occur as a result of taking part in the event. You will not be insured. Please get your own insurance to compete.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 Please type full name as signature:* 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, including (but not limited to) any of the following names: Marc Edwards / Marc Edwards Fitness / K5 Health and Fitness / Universal Training Academy / Universal Training / Universal Fitness Training / Universal Martial Arts Training / Universal Personal Training / K500 Kickboxing / PTSOS / Shipston Personal Training / WAKO GBI 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.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 insuredNameThis field is for validation purposes and should be left unchanged.
