Chris FIIT Youth boxing + Self-Defense Survey

1.Participant Full Name:(Required.)

2.Participant DOB & Age:(Required.)

3.Parent/Guardian Full Name, Phone # & Email(Required.)

4.Does the Participant Have Any Medical Conditions (Asthma, Diabetes, Allergies)? If Yes, Please Describe:(Required.)

5.Does the Participant Take Any Medications? If yes, Please Describe:(Required.)

6.What Skills Are You Hoping Your Child Gains From The Program?(Required.)

7.Are There Any Behavioral Issues We Should Be Aware Of? If Yes, Please Explain:(Required.)

8.Has Your Child Participated In Boxing Or Martial Arts Before? If So, Which Art & How Long:(Required.)

9.Payment Options|Cash, Cash App & Apple Pay $ChrisFIIT777
*No refunds, credits only*(Required.)

Full Payment: $104 (Due by July 15th)

Split Payment;
1st Payment: $52 (Due by July 15th)
2nd Payment: $52 (Due by August 16th)

10.I, the parent or legal guardian of the above-named participant,
understand that participation in physical activities such as boxing and self-defense
involves inherent risks, including but not limited to physical injury, illness, or other
unforeseen consequences.

I voluntarily agree to the following:

1. I release, waive, discharge, and hold harmless Chris FIIT, its instructors, staff,
volunteers, and facility owners (Christ Miracle & Healing Center Church) from any and all liability, claims, demands,
actions, or causes of action arising out of or related to any loss, damage, or
injury, including death, that may be sustained by the participant during the
program.
2. I understand that safety measures will be observed, but physical contact and
movement involve risks.
3. I certify that my child is physically fit to participate and has no known condition
that would prevent safe participation.
4. I give consent for emergency medical care if necessary.
5. I allow Chris FIIT to use photos or videos of the participant for program promotion
unless otherwise requested in writing.
6.The parties agree that this Agreement and related documents may be signed electronically, and such electronic signatures will have the same legal effect as handwritten signatures. An executed copy delivered electronically, including PDF, will be considered as effective as a manually signed counterpart

I, the parent/guardian of the participant, agree to enroll my child in the 13-week
program. I agree to abide by all policies and communicate promptly regarding
attendance or issues. I understand the payment obligations outlined above and agree to
fulfill them in a timely manner.

Full Name:
Date:(Required.)

Chris FIIT Youth boxing + Self-Defense

Youth Consultation