Wanna Be a Kickboxer - Enrolment Forms January

Wanna Be A Kickboxer Boonchu Gym, Training Centre

7/9 Kortum Drive Burleigh Heads QLD 4220 Mobile: 0415-114-972 www.wannabeakickboxer.com.au

ENROLMENT INFORMATION

Name:

Date of Birth: Mobile: Phone:

Current Address:

City: State: Post Code:

Email:

Shirt Size: Training Shirts cost $20

Your Height: Medicare No:

Your Weight: Valid Date:

EMERGENCY CONTACT

Emergent Contact Name:

Address: Relationship:

Phone: Mobile: Email:

TRAINING TIMES

Please select training times you will be attending:

5AM – 6.30AM 6.30PM -8.00PM

Please select training days you will be attending:

Tuesday

Wednesday

Thursday

Friday

Saturday

*We request that you arrive 5 minutes before any training session

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http://www.wannabeakickboxer.com.au/



GOAL SETTING

What are your fitness goals or specific health objectives?

What type of activities do you currently perform or enjoy?

How do you plan to attain your goals? What is your motivation?

Please list any other questions, comments or concerns you have.

EQUIPMENT

Equipment you are to supply:

Mouth Guard

Wrist Wraps

Towel

Water

Sale day at Planet Max located at 109 W Burleigh Rd, Burleigh Heads from 9AM on Saturday 18th January 2014, Heavily discounted price on gloves, wrist wraps and supplements

BIO SCANS

We are happy to offer Bio Scans at this once only special price, this scan is used to measure the total body percentage fat, lean muscle and much more. This will give us the best induction of how much body fat you lose and muscle gained over the duration of the course.

Scans are available from 4th January at HPC Gym located at 39 Hillcrest Parade, Miami.

Cost of scan is $25.

Bookings are essential, please select below:

Yes No

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HEATLTH QUESTIONNAIRE

Do you or have you ever had: If yes Please Explain

Difficulty in Breathing No Yes

Pain or tightness in the chest No Yes

Palpitation/pounding of the heart No Yes

High blood pressure No Yes

High cholesterol/Triglyceride No Yes

Rheumatic Fever No Yes

Any heart/stroke condition No Yes

Blood Clots in leg No Yes

Varicose veins No Yes

Asthma No Yes

Pneumonia No Yes

Chronic Cough No Yes

Stomach/Duodenal Ulcer No Yes

Liver Condition No Yes

Diabetes No Yes

Arthritis/Joint/Muscular pain No Yes

Hernia No Yes

Cramps No Yes

Nervous/mental illness No Yes

Do you Smoke No Yes

Are there any medical conditions that may modify your program?

Are you pregnant?

Do you often feel faint or have spells of severe dizziness?

Has anyone in your family suffered coronary heart disease?

Has a doctor ever said that you have a severe bone or joint problem such as arthritis, that may be aggravated by exercise?

Are you over the age of 35 and not accustomed to vigorous exercise?

Is there a physical reason not yet mentioned why you would not follow an activity program?

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DOCTORS INFORMATION

Name:

Contact Number:

Current Address:

City: State: Postcode:

TERMS AND CONDITIONS

I _______________________ am fully aware that participation with ‘Wanna Be A Kickboxer’ and Boonchu Gym is at my own risk. ‘Wanna Be a Kickboxer’ owner, staff, trainers, operators, members, or friends, are not in any way responsible for injuries to self; damages, and or loss of equipment or personal belongings. Outside ‘Wanna Be a Kickboxer’ events and competitions are also at my own risk. I completely understand that ‘Wanna Be A Kickboxer’ offers a contact sport, full contact sparring included.

I_______________________ understand that I’m required to purchase my own mouth guard, Wanna be a Kickboxer will supply all other safety equipment you’re required to wearI _______________________ confirm I am in excellent physical condition and realize that Muay Thai/kickboxing/Martial Arts is a full contact sport. I accept all risk and will NOT hold ‘Wanna Be A Kickboxer’ or any parties involved or my training partners, responsible for any liabilities or injuries eg bruises, broken bones, dislocated bones, paralysis or death. I fully understand the possibilities and consequences associated with my participation in this Martial Art. I also agree that the gym owners or staff have no obligation to compensate me for any injuries, lost or stolen equipment.

I _______________________ understand there is a cancellation fee of $500.00 If I choose to cancel or terminate my enrolment, cancellations require 30 days written notice. I am also aware that at any time ‘Wanna Be A Kickboxer’ Directors and staff reserve the right to cancel or terminate my enrolment in this program.

Full Name:

Signature: Date:

Witness Name:

Signature: Date:

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The 10 week challenge will include 5 training sessions per week including fitness, strength training, technique training, and pad work.

The course will be held at the Boonchu Gym where 10 times world champion John Wayne Parr trains every day.

Start date for this program is Tuesday 21th January 2014 at Boonchu Gym Training Centre, 7/9 Kortum Drive, Burleigh Heads.

Cost:

The cost of this course is $1800.00 if you choose to pay upfront you can pay by cash or internet transfer. The alternate payment option available is $130.00 per week on a weekly payment plan. Please tick you option below:

I wish to pay full payment of $1800.00 by 4th January 2014

I wish to go under a payment agreement and request the installment plan form

You are required to bring a towel to every lesson and wear comfortable clothes. You can purchase a training shirt from ‘Wanna Be A Kickboxer’ at the cost of $20.

Request Shirt: Yes No

BANK DETAILS

Bank: Westpac Banking Corporation

Account Name: Wanna Be A Kickboxer Pty Ltd

BSB: 034 – 637

Account Number: 485 – 792

When doing a internet transfer please use your surname as the reference

TALENT REQUEST

I hereby consent for all photography and videotapes taken of me and/or recordings made of my voice in whole or in part, of such recordings for the purposes of illustration, broadcast, or distribution in any manner. Wanna Be A Kickboxer reserves all rights to use

photography and video.

I Do consent I Do Not consent

Full Name

Signature

Witness Name

Signature

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Documents

Wanna Be a Kickboxer - Enrolment Forms January