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 Which class will you or your Dragon be attending?*Tuesday Junior Dragons 3:45-4:30 Age 6-10Tuesday Junior Dragons 4:45-5:30 Age 10-15Tuesday Adult Beginner 6:30-7:30Tuesday Adult Advanced 7:30-8:30Saturday Little Dragons 9:00-9:30 Age 4-6Saturday Junior Dragons 9:45-10:30 Age 6-10Saturday Junior Dragons 10:45-11:30 Age 10-15Parent / 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* 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 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 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. .CommentsThis field is for validation purposes and should be left unchanged.
