wanna be a kickboxer - enrolment forms january
TRANSCRIPT
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
1 Enrolment Forms
Wanna Be A Kickboxer Boonchu Gym, Training Centre
7/9 Kortum Drive Burleigh Heads QLD 4220 Mobile: 0415-114-972 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
2 Enrolment Forms
Wanna Be A Kickboxer Boonchu Gym, Training Centre
7/9 Kortum Drive Burleigh Heads QLD 4220 Mobile: 0415-114-972 www.wannabeakickboxer.com.au
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?
3 Enrolment Forms
Wanna Be A Kickboxer Boonchu Gym, Training Centre
7/9 Kortum Drive Burleigh Heads QLD 4220 Mobile: 0415-114-972 www.wannabeakickboxer.com.au
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:
4 Enrolment Forms
Wanna Be A Kickboxer Boonchu Gym, Training Centre
7/9 Kortum Drive Burleigh Heads QLD 4220 Mobile: 0415-114-972 www.wannabeakickboxer.com.au
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
5 Enrolment Forms