BOXING CANADA

MEMBERSHIP APPLICATION

Provincial Association

British ColumbiaAlbertaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon

Registration Status

New

Renewal

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

Address

City

Postal Code

Telephone

Email

Citizenship

Aboriginal Heritage

Yes

No

Competitor

Initiation (8-12)

Junior A (11-12)

Junior B (13-14)

Junior C (15-16)

Youth (17-18)

Elite (19)

Master

Other Category

Coach

Official

Other Non Competitor

Associate Member

Recreational Member

Coaching Level

Official Level

Bouts

(Including kick-boxing and other combat sports)

Wins

Gender

Male

Female

Date of Medical Examination

MM slash DD slash YYYY

Previous involvement in Professional Boxing or any combat sport:

Previous Involvement Description

Signature of Applicant

Signature of Parent or Guardian

(for applicants under the age of 18)

Signature of Witness

Witness' Time of Day

Time of day at which the witnesssing signature was made.

Witness' Date

1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31st

Date on which the witnessing signature was made.

Witness' Month

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Month in which the witnessing signature was made.

Witness' Year

Year in which the witnessing signature was made.

Medical Certificate Attached

Yes

No

Medical Certificate

Max. file size: 256 MB.

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