Application form for BOTH Junior and Senior Boxers
Applicant Full Name (required)
Date Of Birth (required)
Gender (required) ---MaleFemale
Address (required)
Postcode (required)
Contact Email (required)
Emergency Contact Name And Number (required)
Have you ever suffered with epilepsy or have Insulin dependent diabetes? (required) ---YesNo
Have you ever suffered a head injury requiring surgery?? (required) ---YesNo
Do you have Hepatitis B/C or HIV infection? (required) ---YesNo
Do you suffer with severe asthma? (required) ---YesNo
Do you have Sickle Cell Disease (not Sickle Cell Trait)? (required) ---YesNo
Do you have Breast implants or significant gynaecological disorders? (required) ---YesNo
Have you ever had eye surgery, including laser, except squint correction? (required) ---YesNo
Have you ever been diagnosed with Heart disease inc high blood pressure? (required) ---YesNo
Have you ever been diagnosed with Lung disease inc asthma, TB or hepatits? (required) ---YesNo
Do you suffer from Kidney disease or Diabetes mellitus? (required) ---YesNo
Have you ever suffered a blood disorder inc haemophilia, sickle cell / anaemia? (required) ---YesNo
Have you ever suffered a head injury requiring hospital treatment? (required) ---YesNo
Have you ever had neurological disease inc epilepsy, fits, faints or dizzy spells? (required) ---YesNo
Have you any back or joint problems? (required) ---YesNo
Have you any eye problems requiring specialist treatment? (required) ---YesNo
Have you any infectious diseases including sexually transmitted diseases? (required) ---YesNo
Have you ever suffered broken bones and had any major operations? (required) ---YesNo
Have you been admitted to hospital for any illness or injury not mentioned above? (required) ---YesNo
Are you currently taking any medication or non-prescribed tablets or supplements? (required) ---YesNo
Does anyone in your family suffer from Sudden Death, sickle cell disease,TB or kidney disease? (required) ---YesNo
Do you suffer from and mental health difficulties? (required) ---YesNo
If you have answered yes to any questions use the space below to give further details
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.
I Can Confirm
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