Hinterland Boxing Club Participant Form

Name:
Email:
Gender: Male Female
D.O.B:
Occupation:
Date:
Address:

Emergency Contact

Relationship:
Phone:

Please Outline Any Health Conditions

Health Conditions:
Previous/Current Injuries:
Prescribed Medication:
Doctor's Name & Contact:

RELEASE OF LIABILITY

In consideration of the acceptance of my application as a participant to the Hinterland Boxing Club Training or Classes I hereby agree to assume all risks attendant upon myself while participating with Hinterland Boxing Club. I hereby waive, release and discharge any and all claims for death, personal injury or property damage which I may have, or which hereafter accrue to me as a result of my participation in the Hinterland Boxing Club. I agree to indemnity and hold harmless from liability the Hinterland Boxing Club and its member’s chapters and/or any of their agents, servants, volunteers or employees by reason of any accident, death, injury or damages to persons or property which I may suffer while participating with the Hinterland Boxing Club. This release is intended to discharge in advance Hinterland Boxing Club, its members chapters and/or any of their agents, servants or employees by any reason of accident, death, injury or damages to persons arising out of or connected in any way with my participation organised by the Hinterland Boxing Club even though liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above. It is further understood and agreed that this waiver, release and assumptions of risk to be binding on my heirs and assigns of me. I agree to assume all responsibilities for any property damage or injury to any person caused by me while participating with the Hinterland Boxing Club. By my signature I indicate that I have read and understood this Waiver of Liability. I am aware that this is a waiver and a release of liability and I voluntary agree to its terms. If I am signing on behalf of a minor child, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

Participant's Name:
Participant's Signature:

Date:
Parent/Guardian Name (if under 18):
Parent/Guardian Signature:

Date: