JOIN US If you’d like to join us, please answer the questions listed in the form below; One of the team will be in touch with you shortly. Boxer Name * First Name Last Name Date Of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Email * Emergency Contact Details Contact Name * First Name Last Name Contact Number * Boxer Health Questions Have you ever suffered with epilepsy or have Insulin dependent diabetes? * No Yes Have you ever suffered a head injury requiring surgery? * No Yes Do you have Hepatitis B/C or HIV infection? * No Yes Do you suffer with severe asthma? * No Yes Do you have Sickle Cell Disease (not Sickle Cell Trait)? * No Yes Do you have Breast implants or significant gynaecological disorders? * No Yes Have you ever had eye surgery, including laser, except squint correction?Have you ever had eye surgery, including laser, except squint correction? * No Yes Have you ever been diagnosed with Heart disease inc high blood pressure? * No Yes Have you ever been diagnosed with Lung disease inc asthma, TB or hepatits? * No Yes Do you suffer from Kidney disease or Diabetes mellitus? * No Yes Have you ever suffered a blood disorder inc haemophilia, sickle cell / anaemia? * No Yes Have you ever suffered a head injury requiring hospital treatment? * No Yes Have you ever had neurological disease inc epilepsy, fits, faints or dizzy spells? * No Yes Have you any back or joint problems? * No Yes Have you any eye problems requiring specialist treatment? * No Yes Have you any infectious diseases including sexually transmitted diseases? * No Yes Have you ever suffered broken bones and had any major operations? * No Yes Have you been admitted to hospital for any illness or injury not mentioned above? * No Yes Are you currently taking any medication or non-prescribed tablets or supplements? * No Yes Does anyone in your family suffer from Sudden Death, sickle cell disease, TB or kidney disease? * No Yes Do you suffer from and mental health difficulties? * No Yes If you have answered yes to any questions use the space below to give further details Boxer Declaration * I can confirm the above answers are to the best of my knowledge and are answered with the best intentions to enable Five Star ABC to make an informed decision on my (or my Son/Daughter’s) application. If successful with their application I give permission for them to take part in all aspects of amateur boxing and accept that it is a contact sport and injuries may occur. Thank you!