Wandsworth Boxing Club Referral /Medical form

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All prospective boxers of Wandsworth Boxing Club are required to complete the Medical form and return it to the Clubs Head Coach Karen Horsford or to the Welfare Officer Nathan Horsford. All details will be kept secure with access restricted to authorised club officers only.

Boxers contact Information

Name *

Date of Birth *

YYYY

Address *

Postcode *

Email Address *

Emergency Contact details

Name *

Phone number: *

Member Medical Information

Please answer the following questions regarding your general health. If you are under 18 years of age, this section should be filled in by a parent or Guardian. If you are unsure of any question, please ask the coaches to explain.

Have you ever been diagnosed with: *

Heart disease including high blood pressure

Lung disease including asthma or TB

Liver disease including hepatitis

Diabetes mellitus

Any blood disorder including haemophilia, sickle cell/anaemia

Head injury requiring hospital treatment

Other neurological disease including epilepsy, fits, faints or dizzy spells

Eye Problems requiring specialist treatment

Infectious diseases including sexually-transmitted diseases

Breast disease requiring surgery-including implants (female boxers only)

Significant gynaecological disorders (female boxers only)

None of the above

Required

Any other illnesses, injury, operations not listed above? (Please list) *

Are you currently taking, any medication from your doctor? (Please list) *

Have you ever collapsed? (Please give further details)Y/N *

Family History

Does anyone in your family died suddenly under the age of 40 years (males) or 50years (females) Y/N. *

Yes

If you have answered yes to any of the above medical history/family history questions, please provide us with a doctors letter advising us that you are fit to do boxing training

As far as you are aware do you have any allergies? (Please list) *

If yes do you need to carry medication with you? *

Yes

Do you wear dental braces? *

Yes

Do you wear glasses or contact lenses *

Yes

Declaration I consider ,myself / my son/ daughter, to be physically fit and capable of full participation and agree to notify the club of any changes to the medical information provided. Furthermore, in the event that I am injured I give my permission ( for my son/daughter) for the team managers/coaches appointed by Wandsworth Boxing Club to obtain emergency treatment on my behalf.

Signed (type name) *

Date *

YYYY

Relationship

Under 18 boxers consent (to be completed by parent/guardian) Parental consent is provided for participation, transportation and photography. Wandsworth Boxing Club adheres to England Boxing safeguarding policy.

TRANSPORTATION: I consent for my son/ daughter* travelling to venues for matches and training by transport provided by the club which may include travelling in other players private cars.

Signed (type name)

Date

YYYY

Relationship

PHOTOGRAPHY: I am aware that there may be times that photographs and/ or footage may be taken during training sessions by approved agents. Such images shall only be used for publicity/training purposes in accordance with the Wandsworth Boxing Club privacy policy. I give consent for my son/ daughter* to feature in such photos/ images. I hereby only approved agents the right to be used the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes i.e. local newspapers, local magazines, other promotional articles (inc. flyers) and the clubs web pages.

Signed (type name)

Date

YYYY

Relationship

Over 18 member consent

PHOTOGRAPHY: I am aware that there may be times that photographs and/ or footage may be taken during training sessions by approved agents. Such images shall only be used for publicity/training purposes in accordance with Wandsworth Boxing Club privacy policy. I give consent to feature in such photos/ images. I hereby only approved agents the right to be used the images resulting from the photo/film shoots. This includes any reproductions or adaptations of the images for all general purposes i.e. local newspapers, local magazines, other promotional articles (inc. flyers) and the clubs web pages.

Signed (type name)

Date

YYYY

Ethnic and disability

This section is not compulsoryHowever Wandsworth Boxing club is committed to promoting and developing sports equity. Data provided can identify any issues relating to under representation of different groups and can be used to develop strategies to ensure that all people have the opportunity in the future to develop and progress in sports.

Please select

Caribbean black

African black

Asian

Chinese

White European

White English

White Irish

Mixed race

Other:

Clear selection

Please indicate below any learning, mental or physical disabilities.

Submit

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