Registration Form – All Courses Pink Belt Kickboxing Registration Form Lifestyle Questionnaire and PARQ for Pink Belt Kickboxing Programme Welcome to the first step in your journey to some kick ass fitness and awesome skill. Please fill in the form below. This will give us a clear indication of your Medical History, Fitness Levels & Injuries etc. Please be as honest and as detailed as possible. Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date of Birth* DD slash MM slash YYYY Next of Kin Name* Next of Kin Contact Number* Doctor Name* Doctor Surgery / Contact* Do you suffer / Have you suffered from any of the following? Rheumatoid or Osteo Arthritis Head / Neck Injury Shoulder/Arm/Wrist/Hand Injury Back Pain / Injury Hip / Pelvis Injury Do you suffer / Have you suffered from any of the following? Knee / Thigh / Leg Injury Ankle / Foot Injury Nerve Damage Swollen Joints Fractured Bones Do you suffer / Have you suffered from any of the following? Heart Problems Diabetes Epilepsy Early menopause Cancer If You answered yes above, please provide detailsAre you currently recieving treatment for anything? Yes No Have you had major surgery in the last 10 years? Yes No Have you had minor surgery in the last 2 years? Yes No If you answered yes to the above, please provide detailsDo you suffer / have you suffered OR have you ever had a medical consultation for any of the following conditions?AsthmaEpilepsyHigh / Low Blood PressureHeart Conditions / ProblemsChest PainsIf You answered yes above, please provide detailsAny other health issues not already mentioned, please list here:Are you pregnant? Yes No Have you ever participated in a Martial Art or Martial Sport before?* Yes No If you answered 'Yes' to the above question, what? (please detail) Have you ever been diagnosed with a learning disability / have any problems learning in school / require any special provision for assessments because of learning issues?* Yes No I understand that certain elements of the Sessions/Course can be physically demanding. I accept full & complete responsibility for my participation in the practical elements of this session/course* Yes I agree that Pink Belt Kickboxing, Universal-Training, Marc Edwards Fitness & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by my participation* Yes I agree that Pink Belt Kickboxing, Universal Training, Marc Edwards Fitness & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by this training with 3rd parties* Yes I understand that by signing this / completing this form that any use of excersises post course/workshop/session, I assume all responsibility for demonstrations and the safety of the end user* Yes Pink Belt Kickboxing, Universal Training, Marc Edwards Fitness and Representatives means anybody delivering a training session / Course / Workshop in association with / on behalf of Marc Edwards or Associated Training Provider (REPs Accredited or not) and any Training Session/Course/Class/Workshops including (but not limited to) any of the following names: Marc Edwards Fitness / K5 Health and Fitness / Universal Training / Universal Fitness Training / Universal Martial Arts Training / Universal Personal Training / K500 Kickboxing / Jordan Fitness / WAKO GB / Quantum HFE / Leisure Lines GB / BeaverFit / Pink Belt KickboxingCAPTCHACommentsThis field is for validation purposes and should be left unchanged. 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