Boxing Registration Form

Barack Community Recreation Center
Boxing Registration Forms
580 E Woodrow Ave, Columbus, OH 43207
Participant's Information
Participant's Name*
First NameLast Name
Are you over 18 ?*
YesNo
Participant's /Legal Guardian Name*
First NameLast Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Home Phone*
Area CodePhone Number
Cell Phone
Area CodePhone Number
E-mail*
Boxing skill level*

1 2 3 4 5
1 is Begginer, 5 is Advanced
Interested in Competiting?
YesNo
List below the following reasons you decided to join this boxing program? (Examples : Strengthening upper- body and core. Boosts endurance. Improving hand-eye coordination, competing, confidence etc. )
Important Notes · Dress appropriately. · No food or drink in the gym ( only water ). · Keep the gym clean. · The league organizers (Coaches) reserve the right to ensure the talents of all participants by categorizing in proper weight class to balance teams. · Fee: $100 (one time charge) per child and $150 monthly charge for Adults (+18 and up). · Included in the fee will be (1) pair of Bag Gloves, Boxing wrap ( to protect hands) and Boxing shoes ( optional, additional $25 charge). Open Gym is a free workout day !

Hours of Operation
Monday : Temporary Closed
Tuesday : Youth 4-5:30pm, 6-8pm Adults
Wednesday : Youth 4-5:30pm, 6-8pm Adults
Thursday : (OPEN GYM)
Friday : Youth 4-5:30pm, 6-8pm Adults
Saturday : Noon to 5 pm ( OPEN GYM )
Emergency Contact & Health Insurance Information
Emergency Contact's Name*
First NameLast Name
Relationship*
Phone Number*
Area CodePhone Number
Do you have health insurance ?
YesNo, I'll pay with cash.
Insurance Carrier
Name of Policy Holder
Subscriver ID/Group Number
Card Number / Card Date
Does you have any allergies, breathing conditions , or medical conditions that would limit high level activtiy?*
YesNo
Please describe*
Parental Permission For Emergency TreatmentIn the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to: I give consent for the facility to secure any and all necessary emergency medical care for my child.
Name of Physician / Emergency Medical Care Facility
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
Release of Liability Although the safety of all sport activities is the primary concern, indoor sport activities at Barack Community Recreation Center facility may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against the Barack Community Recreation Center and the persons in charge.
I have read and agree to the above conditions*
YesNo
Confirmation E-mail*
Signature*
Clear
After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at gxtt.basketball@gmail.com.
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