Medical History and Release Form

If you have submitted the pre-registration form, Print this form, complete, sign and return with a check for the amount of $295 per child per camp.

Idrise Ward-EL
PMB #266
49-950 Jefferson St. suite 130
Indio CA 92201

Name of Parent:_______________________________________________________________
Name of Child:__________________________________ Date:_______________________
Address:____________________________________ Birthdate:_________ Male / Female
City:___________________________________ Phone:_____________________________

1. Write in "YES" or "NO" to each of the following questions:
   ______Physically Inactive (YES if you have not been exercising or active in a sport for 2+ months)
   ______Uneven, irregular or skipping heart beat (includes racing or fluttering)
   ______High cholesterol
   ______Family history of Heart disease: Male age 55 or less, Female age 65 or less
   ______Back problems
   ______Cervical problems/neck
   ______Thoracic /Mid back
   ______Lumber /Lower back
   ______Diabetes
   ______Asthma, bronchitis or Emphysema
   ______Shortness of breath (with no physical exertion)
   ______Light-headness or fainting (no apparent reason)
   ______Smoking
   ______Any other injuries or Illness not listed above
   ______Is your son or daughter taking any type of prescription medications?
   1. 
      If so, please explain:_____________________________________________________
   2. 
      
2. Any Limitations/ Special doctor's orders:_________________________________________
   Doctor’s Name:____________________________________Phone:____________________
   Emergency contact:____________________________________ Phone:__________________________
3. 
   By signing this document, I acknowledge that I have been informed of the possible need to obtain a
   physician’s examination and approval prior to beginning the Boxing Camp program for my child. I further understand that the boxing program my be strenuous and possibly dangerous and choose to let my child participate completely voluntarily. I accept all responsibility for my child’s health in any way. I hold harmless of any responsibility, the instructor, facility and or any persons involved in the program.
4. 
   Print Name of Parent:_____________________________________
   Signature:_______________________________________________ Date:_______________________