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 25, 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 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 *
Name *
Address *
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
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: