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APPLICATION FORM

SPAR-MATE BOXING GYM
POWERED BY FIRMSPORTS, INC.
Wesleyan College of Manila, 4th floor,
Leveriza cor. Balagtas St., Pasay City

APPLICATION FOR MEMBERSHIP

 
PERSONAL INFO:
Full Name:
Occupation:
Address:
Tel. No.:
Birth Date:
Sex: Weight: Hieght:
Person to Notify Incase of Emergency:
Relationship:
Address:
Tel. No.:
   

HEALTH HISTORY:  We would like to know your physical condition. Please read very carefully the following checklist and answer the same accordingly:  DO YOU HAVE ANY OF THE FOLLOWING?
1. Heart Problem, chest pain or stroke
2. Increased blood pressure Yes No
3. Any chronic illness or condition Yes No
4. Difficulty with physical exercise Yes No
5. Advised by a doctor not to exercise Yes No
6. Surgery during the last 12 months Yes No
7. Muscle, joint pain affecting movement Yes No
8. Diabetes or thyroid condition Yes No
9. Pregnancy Yes No
10. Asthma or difficulty in breathing Yes No
11. Increased blood cholesterol Yes No
12. Hernia or any condition affected by lifting weights Yes No

Do you have any members of your immediate family who has heart problems, asthma and diabetes? Yes No

If YES, state the relationship:

 

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