Q-TRACK

Contact Information

If you have completed this form before, click

First Name

Last Name

Phone Number

DOB

Post Code

Address Detail

Town

County

Allows third party data share

Yes No

Other members of my party Add new

Main Page

Boxers Details

Provide boxers details if different from above i.e child details

First Name of boxer or child if different from above:

Surname of boxer or child if different from above:

Male or Female

Male

Female

DOB (if completing for your child and different from above)

Name of Parent Guardian (if applicable)

NOK / Emergency Contact Name

Relationship to boxer

NOK/ Emergency Contact Number

Second NOK/ Emergency Contact Name

Second NOK/ Emergency Contact Number

Relationship to boxer

Medical Details

Detail any medical conditions

Details of all medical conditions or allergies (e.g Asthma, Diabetes, Epilepsy) and any other medications

Declaration

Provide boxer or parent guardian declaration

I will inform Harlow ABC of any changes to the above details

Yes

In the event of illness or accident, having parent responsibility for the above named child/ myself i give permission for first aid to be administered where considered necessary by a trained first aider, if available, or by a suitably qualified medical practitioner.

Yes

Child / personal photo consent: I hereby give permission for photographs to be taken which may be published on social media, in local news papers, brochures, displays. I am aware this may be accompanied with the boxers name

Yes

Please print boxers or parent guardians full name

Boxer / parent guardians signature