CAYMAN ISLANDS BOXING ASSOCIATION
EXTENDED AFTER-SCHOOL BOXING PROGRAM
The information on this form is considered confidential and will be held in strictest confidence and accessible only
by the gym manager and relevant staff. Filled forms can be emailed back to [email protected] or delivered to our
gym facility during opening hours.
Student’s Name__________________________________________________ Gender: M or F
D.O.B Parent/Guardian Name
Home Phone Home Address
District ______ School Attending
Parent/Guardian #1 Cell Phone
Parent/Guardian #2 Cell Phone
1
st
Emergency Contact Name
Emergency Contact Phone #1 Relationship to student
2
nd
Emergency Contact Name
Emergency Contact Phone #2 Relationship to student
1
st
Authorized Pickup Name & Cell Phone
2
nd
Authorized Pickup Name & Cell Phone
Family Doctor
Special Needs? (Allergies, physical or health concern) _____________________