Application Form

PERSONAL INFORMATION

Full Name*

Age*

Sex*

Male
Female

Weight (kg)*

Height (cm)*

Mobile Number*

Email*

Postal Address

Do you know anyone who has competed in the PCR before?*

Do you have a sponsor or are you able to self finance?*

Yes
No

Who is your sponsor (if applicable)

ADDITIONAL COMMENTS

MEDICAL HISTORY

Do you have any other underlying medical conditions, physical injuries or take ongoing medication? If yes, please specify:*

Yes
No

Specify

Do you have private health insurance (for mouthguard - gap payment )*

Yes
No

EMERGENCY CONTACT

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

I give permission for the DENTISTRY PLUS 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 DENTISTRY PLUS 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

Signature

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BOXER APPLICATION FORM