K500 Kickboxing Registration Form

Name of Student*

First Middle Last

Parent / Guardian Name if student (named above) is under 18

First Middle 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

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 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 understand that certain elements of the Session/Course can be physically demanding. I accept full & complete responsibility for my participation in the practical elements of this session/course*

Yes

I agree that K500 Kickboxing, Marc Edwards Fitness & 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 K500 Kickboxing, Marc Edwards Fitness & 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

Indemnity Disclaimer. I understand that by signing this / completing this form that any use of excersises post course/workshop/session, I assume all responsibility for demonstrations and the safety of the end user*

Yes

K500 Kickboxing, Marc Edwards Fitness and Representatives means anybody delivering a training session / Course / Workshop in association with / on behalf of Marc Edwards or Associated Training Provider (REPs Accredited or not) and any Training Session/Course/Class/Workshops including (but not limited to) any of the following names:

Marc Edwards Fitness / K5 Health and Fitness / Universal Training / Universal Fitness Training / Universal Martial Arts Training / Universal Personal Training / K500 Kickboxing / WAKO GB

Email

This field is for validation purposes and should be left unchanged.

K500 Kickboxing Registration Form

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