Fight PTSOS Fight Registration Name* First Last Address* 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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:*December 10th 2021Please 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 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 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.Covid 19 Consent Form I understand that the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious. I understand that physical distancing of 2 meters may not be possible while in the Studio. Hard surfaces such as door handles, Ipads, payment terminals and all training equipment will be sanitised and wiped prior and after use. I confirm that I am not currently positive for novel coronavirus. I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. I verify that I have not returned to the UK from any country outside of the UK, whether by car, air, bus or train in the past 14 days. I verify that I have not been identified as a contact of someone who has test positive for the novel coronavirus or been asked to self-isolate by The Department of Health, or any other government agency. I confirm that I am not presenting with any of the following symptoms of COVID-19 identified by the CDC Fever > 38C, or 100F, chills or body aches Cough Sore Throat Shortness of breath Difficulty breathing Flu-like symptoms Runny Nose Loss of smell or taste I understand that I may be unable to proceed with services with PTSOS if they are deemed unsafe to myself. I understand Shipston Personal Training & Representatives will do everything possible to minimize the spread of COVID – 19, but will not hold them responsible should I contract the COVID – 19. I will immediately notify the trainer if I contract the virus within two weeks following my visit. .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 insuredPhoneThis field is for validation purposes and should be left unchanged.
