BOXER APPLICATION FORM PERSONAL INFORMATIONFull Name* Age* Sex Male Female Weight (kg)* Height (cm)* Mobile Number* Email* Postal Address How did you hear about PCR? Do You have a sponsor? Yes No Who is your sponsor? MEDICAL HISTORYDo you have any other underlying medical conditions, physical injuries or take ongoing medication? If yes, please specify: Yes No SpecifyEMERGENCY CONTACTEmergency Contact Name Emergency Contact Relationship Emergency Contact Phone I give permission for COUNTERBALANCE FITNESS, GOBSMACKED SPORTS MOUTHGUARDS and GOBSMACKED PERTH CORPORATE RUMBLE to use my image for the events marketing strategy. I understand boxing is a contact and combat sport and I will do my best to listen to my trainers to help provide a safe boxing environment for myself and my fellow boxers. I understand the GOBSMACKED PERTH CORPORATE RUMBLE is a white collar boxing event and I will comply with the rules and regulations to keep the environment during training and the event fun, friendly and safe.* I Accept SignatureUse mouse or touchscreen to sign 67574Δ
