Boxing Gym Membership

Membership Application.

Complete all nine sections below. Applicants under 18 must have a parent or legal guardian sign. Questions? Contact the foundation or call (443) 449-5690.

THE MR. MACK LEWIS FOUNDATION

Boxing Gym & Community Center

Membership Registration Application

913 N. Bond Street, Baltimore, MD 21205 | (443) 449-5690

Section 1: Membership Type

Membership Category *

Adult (ages 18-70) - $600/year or $50/monthYouth (ages 6-17) - $420/year or $35/month

Payment Type *

AnnualMonthly

Program Interest * (Select all that apply)

FitnessBoxingAmateurProfessionalNew MemberTransferring Member

Section 2: Applicant Information

First Name *

Last Name *

Address *

City *

State *

ZIP Code *

Phone *

Alternate Phone

Date of Birth *

Age *

Sex

Height

Weight

Birthplace

Permanent Resident?

YesNo

Section 4: Emergency Contact

First Name *

Last Name *

Phone *

Alternate Phone

Relationship to Applicant *

Section 5: Health Information

Date of Last Physical *

Physician Name

Physician Phone

Current Medications / Recommendations / Medical Notes

Section 6: Demographic Information (Optional)

Used for program reporting and funding purposes

Ethnicity (Select all that apply or choose 'Prefer not to answer')

Black / African AmericanHispanic / LatinoWhite / CaucasianPuerto RicanAmerican Indian / Alaska NativeAsianOtherPrefer not to answer

Section 7: Health Affidavit *

I certify that I have no current hand injuries, fractures, broken bones, head injuries, concussions, fainting spells, recurring headaches, or other medical conditions that would prevent me from safely participating in boxing, fitness, training, sparring, or related activities. I agree to notify gym staff immediately if any injury or condition occurs.

I certify the above is true *

Section 8: Waiver & Release of Liability *

In consideration of the acceptance of my application and participation at The Mr. Mack Lewis Foundation Boxing Gym, I hereby waive, release, and discharge any claims for death, personal injury, bodily injury, illness, property damage, or other damages arising from my participation. I understand that boxing and fitness training involve inherent risks.

I agree to indemnify and hold harmless The Mr. Mack Lewis Foundation, its board members, coaches, trainers, agents, volunteers, and employees from any liability, claims, demands, damages, losses, costs, or expenses arising out of or connected with my participation.

For minor participants: I am the parent/legal guardian. I certify my child is physically fit to participate. I consent to my child's participation and agree this waiver binds me, my child, my heirs, legal representatives, and assigns. I release and hold harmless The Mr. Mack Lewis Foundation from any claim, liability, injury, damage, cost, or expense including attorney fees.

This release applies to claims arising from negligence or carelessness to the fullest extent permitted by law.

I have read and agree to the Waiver & Release of Liability *

Section 9: Electronic Signature *

Applicant Name (Type your full name as signature) *

Date *

By submitting this form, you agree that your electronic signature is legally binding.