First Name

Last Name

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Is this form being filled on behalf of the student?

I declare that the information given in this form is true and complete to the best of my knowledge and consent to the above mentioned becoming a member of the West City Boxing Academy. *

I give my express permission that all photos taken and video footage recorded by WCB during the membership can be used by the West City Boxing Academy or by any third party (such as Funders) with the consent of the West Auckland Youth Development Trust/West City Boxing Academy, including use on Social Media (Website, Facebook, Instagram, YouTube). *

I acknowledge that West Auckland Youth Development Trust/West City Boxing Academy has a Vulnerable Children’s Policy and will follow this if this member is deemed to be at risk. (If you would like to view this policy please check out our website for more information - www.westcityboxing.nz ) *

I accept that the possibility of injury is inherent in undertaking physical activity (e.g. boxing). I will not hold West Auckland Youth Development Trust/West City Boxing Academy responsible for any injury or loss associated with this member while attending the Academy. *

I give my express permission for West Auckland Youth Development Trust/West City Boxing Academy to take all responsible action to seek medical attention this member require it at my own expense. *

I acknowledge that in accordance with the provisions of the Privacy Act 1993, the following information has been brought to my attention: This form collects sensitive personal information about me and/or a child under my care. *

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Youth Girls (15-18 Years) Waitlist – Payment

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