K500 Kickboxing Registration Form K500 Dragons - Registration Form Lifestyle Questionnaire and PARQ for K500 Kickboxing, Dragins by K500, Universal Training, Marc Edwards Fitness and Associated parties 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 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* Date Format: 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?YesNoHave you had major surgery in the last 10 years?YesNoHave you had minor surgery in the last 2 years?YesNoIf 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?YesNoHave you ever been diagnosed with a learning disability / have any problems learning in school / require any special provision for assessments because of learning issues?*YesNoI 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*YesI 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*YesI 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*YesIndemnity 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*YesK500 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 GBNameThis field is for validation purposes and should be left unchanged.