Testing Ground Smoker Fight Series

Medical and Official Weigh-In Form

First name

Last name

Mobile Number

Birthday

Day

Month

Year

The name of the training centre that you are representing

Your coach's name

Your coach's mobile number

Your emergency contacts name

Your emergency contact's mobile number.

Your Medical History

Medical History Multi choice

Do you smoke/vape?

Do you consume alcohol?

Have you had a concussion in the last 6 months?

Do you have any surgical implants?

Do you have a history of seizures?

Do you have any issues with your eye sight?

Do you have any issues with your hearing?

Have you had any injuries to your spine?

Are you currently taking any medication?

Additional Medical History

Please provide additional information for any boxes you have ticked above. For example, the type of medication being taken or how often you consume alcohol.

Upload a copy of your blood test

I hereby declare that to the best of my knowledge, all the information I have provided in writing or by ticking the boxes is correct and accurate. Signature

Testing Ground Smoker Fight Series

Medical and Official Weigh-In Form

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