Name *

First Name

Last Name

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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

Do you know of any other reason why you should not do physical activity? *

Yes

No

If answered yes to any of the above conditions please confirm that your doctor has agreed to you taking part in boxing training? *

Yes

No

I understand that participation in boxing, boxing training and associated fitness activities could include actions or tasks which might be hazardous to me. I assume any risk of harm or injury which might occur to me in my participation in the activity. I release Undisputed Boxing from all liability, costs and damages which might arise from my participation in the above named activity. *

Please Tick To Confirm Signature

Name *

First Name

Last Name