Application

 

We are very pleased to welcome you to the Fighting Life Boxing/Academic program. To ensure we have the correct contact details for you, please fill out this form.

Attention: If you are under the age of 17, a consent form MUST be signed in person with a parent or guardian at UpperKuts Boxing Club. Please visit our gym for the consent form or email aj@upperkutsboxing.com to have the consent form emailed to you in advance for signature. Once signed please bring to 30 Main St, Ashland, MA.

 
 
Section 1: Personal Details
Date *
Date
Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Do you get subsidized school lunch? *
Are you in need of transportation? *
Do you need extra help in academics? *
What subject(s) do you need help in?
Section 2: Ethnicity
In order to help the club monitor its membership please check one of the following boxes to identify your ethnic group/origin:
A. White
B. Mixed
C. Asian or Asian British Pakistani
D. Black or Black British
E. Chinese or other ethnic group
Disability
The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’.
Do you consider yourself to have a disability? *
If yes, what is the nature of your disability (Check below)?:
Boxing Information
Have you boxed before? *
If 'YES', where have you boxed?
Medical Information
Emergency Contact Details
Please insert the information below to indicate the person(s) who should be contacted in event of an incident/accident.
Contact name (e.g. spouse/parent/guardian): *
Contact name (e.g. spouse/parent/guardian):
Emergency contact number: *
Emergency contact number: