Name *

First Name

Last Name

Phone *

(###)

###

####

Has the participant lost consciousness for any reason in the last 3 months? *

Yes

No

Has the participant ever sustained a serious head injury? *

Yes

No

Does the participant suffer from fits, fainting, migraines or diabetes? *

Yes

No

Does the participant have any behavioural/educational needs? *

Yes

No

Does the participant have a disability? *

Yes

No

Is there anything else Fight For Your Future CIC should be aware of in regards to the health and welfare of the participant? *

Yes

No

I consent to Fight for Your Future CIC using photographs and/or video recordings of me taken by Fight for Your Future or others authorised on their behalf, for the purposes of internally and externally promoting the community interest company. These images could be used in any media, including print and digital media formats such as print publications, brochures, websites, e-marketing, posters, banners, advertising, film, social media, teaching and research purposes. *

I consent for the participant to take part in contact elements including sparring, once coaches view them to be of a suitable standard *