Fighter Sign Up - Exhibition Fight Night

EXHIBITION FIGHT NIGHT

Fighter Registration + Waiver

*You must have a current USA Boxing membership and physical examination to participate in this event.

Athlete Full Name*
Athlete Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Athlete Email*
Phone #*
Age*
Weight*
Fight Experience (Number of Fights)*
USAB Member #*
Athlete Date of Birth*
MM slash DD slash YYYY
Medications, important medical info: or special instructions:
List any restrictions to medical treatment:
Physician/HMO Name:
Emergency Contact Person (first & last name):*
First Last
Emergency Contact Phone Number*
Gym Affiliation*
Coach Name*
Coach Phone #*
Coach Email Address*
Release of Liability*
In the consideration of the acceptance of my application as a participant to Exhibition Fight Night (EFN) , I hereby agree to assume all risks attendant upon me while participating in this event . I hereby waive, release, and discharge any and all claims for death, personal injury, or property damage which I may have, or which may hereafter accrue to me, as a result of my participation in EFN. I agree to indemnify and hold harmless from liability EFN, The Bloc Chicago, and/or any of their venues, agents, sponsors, affiliates, or employees by any reason of any accident, death, injury, or damages to persons or property which I may suffer, from and against any and all liability arising out of or connected in any way with my participation organized EFN even though that liability may arise of negligence or carelessness on the part of the persons or entities mentioned above.

It is further understood and agreed that this waiver release and assumption of risk be binding on my heirs and assigns of me. I agree to assume all responsibilities for any property damages or injury to any person caused by me while participating in EFN and/or training/sparring/boxing.
By checking this box, I agree that I have read and understand the release of liability.
Athlete Signature*
How Did You Hear About Us?*