Keep Swinging Boxing

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1. Personal Information

Full Name

Date of Birth

Age

Gender (Male, Female, Other, Prefer not to say)

Phone Number

Email Address

Emergency Contact Name

Emergency Contact Phone

2. Class Selection (Checkboxes – allow multiple)

Beginners Boxind

Intermediate Boxing

Youth Boxing (Ages 8-14)

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3. Payment Information

Membership Options

$50.00/month – Registration required

$185.00/3 months – Registration waived, boxer provides own equipment

$300.00/6 months – Registration waived, includes hand wraps, jump rope, mouthpiece

$600.00/year – Registration waived, includes hand wraps, jump rope, mouthpiece, gloves

5 Class Pass – $30.00

One-Time Drop-In Class – $10.00

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Payment Method (Checkboxes)

Cash

Credit/Debit Card

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Please Scan this Code for Payment

Date of Payment (Date)
Received By (confirmation code or receipt number)

4. Scholarship Application (Optional)

Would you like to apply for a scholarship?

If selected, I agree to complete a minimum of 10 volunteer hours each month at The Restoration Center to maintain my scholarship status. Please

Yes, I would like to apply.

No I do not wish to apply

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Why are you interested in the scholarship and working with the Restoration Center?

For Internal office use only

Application approved or not approved by:

5. Waiver & Agreement

I understand that participation in physical training and boxing carries potential risk.
I agree to follow all safety guidelines and instructions.
I release Keep Swinging Boxing Academy, The Restoration Center, and its staff from liability for any injury or loss.

Signature (Type Full Name)
Date
Parent/Guardian Signature (if under 18) Witnessed by____________________

(Please Digitally Sign Below)

Do you agree to the waiver above?

Yes

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