MARTINEZ BOXING

MEDICAL AND EMERGENCY INFORMATION FORM

Confidential operational form — not a medical examination or diagnosis

Martinez Boxing LLC
2204 Shorter Ave NW, Suite 20, Rome, GA 30165
(706) 622-8833 | info@martinezboxinggym.com

Medical discussions should occur as privately as reasonably possible. Staff should avoid discussing sensitive medical information within camera view or hearing of others when a more private, safe alternative is available. No security camera is placed in the restroom.

DISCLOSE INFORMATION NEEDED FOR SAFE PARTICIPATION. CALL 911 FOR EMERGENCIES; DO NOT USE THIS FORM TO REQUEST URGENT MEDICAL CARE.

Participant: {name}
Date of Birth: {dob}
Address: {address}
Phone: {phone}

Emergency Contact: {contact_name}
Emergency Contact Relationship: {contact_relation}
Emergency Contact Phone: {contact_phone}

1. Additional Medical Contact Information

Primary physician / phone (optional):

Health insurer / member ID (optional):

2. Health Information

Allergies, including medication or latex
If none, enter “None.”

Current medications / rescue medications
If none, enter “None.”

Asthma or breathing condition
Enter “No” or “Yes” and provide details if applicable.

Heart, circulation, or blood-pressure condition
Enter “No” or “Yes” and provide details if applicable.

Seizure, fainting, diabetes, or neurological condition
Enter “No” or “Yes” and provide details if applicable.

Bone, joint, back, neck, hand, or prior surgical condition
Enter “No” or “Yes” and provide details if applicable.

Prior concussion, head injury, knockout, or loss of consciousness
Enter “No” or “Yes.” If yes, provide the date and details.

Pregnancy or possible pregnancy — optional disclosure
Enter “No,” “Yes,” “Prefer to discuss privately,” or leave blank.

Current injury, pain, symptoms, or restriction
If none, enter “None.”

Healthcare-provider restrictions
If none, enter “None.”

Other information staff should know
If none, enter “None.”

3. Emergency Authorization

If I cannot make or communicate a decision, I authorize staff to contact emergency services, my emergency contact, and the parent/guardian of a minor, and to provide or arrange first aid, CPR, AED use, transportation, and emergency evaluation.

I understand this does not require the Gym to provide medical care and does not guarantee an outcome.

I accept responsibility for costs except where law requires otherwise.

4. Accuracy, Updates and Privacy

I certify this information is accurate and will update it when circumstances change.

The Gym may share necessary information with coaches, emergency responders, healthcare providers, and a minor’s parent/guardian for legitimate safety and operational purposes.

The Gym will use reasonable safeguards, but this form is not a promise of HIPAA coverage or absolute confidentiality.

SIGNATURE AND ACKNOWLEDGMENT

I certify that I have read this entire document, understand it, had the opportunity to ask questions, and sign it voluntarily.

I understand that I am giving up substantial legal rights, including the right to sue for claims released by this agreement.

Participant: {name}
Date of Birth: {dob}
Signer / Parent or Guardian, if applicable:
Date: {sign_date}

MARTINEZ BOXING LLC
2204 Shorter Ave NW, Suite 20
Rome, GA 30165

VISITOR / FREE INTRO / DAY PASS WAIVER AND PARTICIPATION AGREEMENT

Participant Name: {name}
Date of Birth: {dob}
Phone: {phone}
Emergency Contact: {contact_name}
Emergency Contact Phone: {contact_phone}
Relationship: {contact_relation}

ASSUMPTION OF RISK

I understand that boxing, fitness training, exercise, use of boxing equipment, and related activities involve inherent risks, including falls, strains, sprains, cuts, bruises, fractures, head injury, concussion, and other serious injury.

I voluntarily choose to participate and accept the risks associated with these activities.

RELEASE AND WAIVER

To the fullest extent permitted by law, I release and hold harmless Martinez Boxing LLC, its owners, coaches, staff, agents, and representatives from claims arising from the ordinary risks of my voluntary participation, except to the extent a claim cannot legally be waived.

RULES AND SAFETY

I agree to follow all Martinez Boxing rules, posted safety requirements, and staff instructions.

Unsafe conduct, unauthorized coaching, violence outside supervised training, misuse of equipment, and unsupervised sparring are prohibited.

Signing this waiver does not authorize me to spar. Sparring requires separate approval and any additional consent required by Martinez Boxing.

FREE INTRO / PASS TERMS

A free introductory class is limited to one per first-time visitor, age 6 or older, subject to registration, required waiver, class capacity, and staff approval.

Free introductory participants may not spar.

A single scheduled class pass is $15.

A full-day pass is $25 and permits access only to eligible scheduled classes or approved staffed training periods.

Day passes do not include private coaching, unrestricted ring use, unsupervised sparring, or automatic competition-team participation.

MEDICAL AND EMERGENCY AUTHORIZATION

I certify that I am physically able to participate or will notify Martinez Boxing of any condition that may affect safe participation.

If emergency medical care is reasonably necessary and I am unable to provide consent, I authorize Martinez Boxing staff to contact emergency services and provide reasonably necessary information to responders.

MINORS

For any participant under 18, a parent or legal guardian must complete and sign this waiver.

The parent or legal guardian accepts these terms on behalf of the minor and authorizes the minor’s participation subject to Martinez Boxing rules and staff supervision.

ACKNOWLEDGMENT

I have read and understand this document. I understand that participation is voluntary and that this document affects legal rights.

Participant / Parent or Legal Guardian:
Participant: {name}
Date Signed: {sign_date}

Set Signature Needed = YES.