2016 CLEVELAND AREA GOLDEN GLOVES 88th ANNUAL QUALIFYING TOURNAMENT

OFFICIAL BOXING ENTRY FORM

Competition Dates ~ April 22, 23,29,and30,2016

All events will be held at the

Brook Park Recreation Center,

17400 Holland Rd. Brook Park, Ohio 44142

PLEASE CHECK THE CORRECT DIVISION: Sub-Novice ◌ Novice ◌ Open ◌

Male  Female 

Name: ______Weight Class: ______

Address: ______

STREETCITYSTATE & ZIP

Phone#: ( ) ______Phone#: ( ) ______Passbook #______

Birth date (mm/dd/yy):______/______/______Actual Age as of (04/01/15) ______

Your email: ______Your Club Name: ______

Coaches Name: ______Coaches Phone #: ( )______

EMERGENCY CONTACT: (during competition)

Name: ______Phone#: ( ) ______

Last Name First Name

Relationship______2ndPhone#: ( ) ______

WAIVER/WARNING

IN CONSIDERATION OF YOUR ACCEPTING HIS ENTRY, I HEREBY, FOR MYSELF, MY HEIRS, EXECUTORS ADMINSTRATORS AND ASSIGNS WAIVE AND RELEASE ANY AND ALL RIGHTS TO ANY CLAIM FOR DAMAGES I MAY OR MIGHT HAVE AGAINST UNTED STATE AMATEUR BOXING (USA BOXING), ANY SANTIONING LOCAL BOXING COMMITTEE OF USA BOIXNG AND ALL SPONSORS AND VENUE OWNERS, OR THE OFFICERS SUB-COMMITTEES AGENTS, REPRESENTATIVES AND ASSIGNS OF THESE ENTITIES, FOR ANY INJURY OR DAMAGE SUFFERED BY ME DURING MY PARTICIPATION IN, AND/OR ARISING FROM TRAVELING TO AND/OR RETURNING FROM THE BELOW LISTED TOURNAMENTS.

I AGREE TO ABIDE BY THE RULES OF THE UNITED STATES AMATEUR BOXING. I FULLY UNDERSTAND THAT I ASSUME ALL RESPONSIBILTIY FOR ANY INJURY OR DAMAGE THAT I MAY INCUR IN THESE BOXING BOUTS. I UNDERSTAND AND AGREE THAT MEDICAL OR OTHER SERVICE RENDERED TO ME BY OR AT THE INSISTENCE OF ANY OF THE NAMED PARTIES IS NOT AN ADMISSION OF LIABILITY TO PROVIDE OR CONTINUE TO PROVIDE ANY SERVICES AND IS NOT A WAIVER BY ANY OF SAID PARTIES OF RIGHT OR RIGHTS HEREUNDER.

I CERTIFY THAT I HAVE NO INJURIES TO MY HANDS, NEITHER FRACTURES NOR BROKEN BONES WITHIN THREE MONTHS PROCEEDING THE DATES OF THIS ENTRY FORM, AND KNOW OF NO OTHER INJURIES TO THE HEAD, CONCUSSION, FAINTING SPELLS, AND WILL NOTIFY BOXING OFFICIALS IMMEDIATELY SHOULD ANY OF THESE INJURIES AND CONDITIONS BE EXPERIENCED IN THE FUTURE.

IN ADDITION, I ALSO UNDERSTAND AND APPRECIATE THAT PARTICIPATION IN THE SPORT OF BOXING CARRIES A RISK TO ME OF SERIOUS INJURY, INCLUDING PERMANENT PARALYSIS OR DEATH; I VOLUNTARILY AND KNOWINGLY RECOGNIZE, ACCEPT AND ASSUME THIS RISK.

FEMALE BOXERS ONLY: I FURTHER CERTIFY THAT I AM NOT PREGNANT, OR HAVE ANY PAINFUL; PELVIC DISCOMFORT SUCH AS SYMPOTOMATIC ENDOMETRIOUSIS OROTHER CAUSES, ABNORMAL VAGINAL BLEEDING OF UNDETERMINED CAUSES (ETIOLOGY), RECENT (SECONDARY AMENORRHEAL, RECENTLY DEVELOPED BREAST DYSFUNCTION PREVIOUSLY NOT PRESENT OR SURGICAL BREAST IMPLANTS, AND HAVE READ SECTION 101.3 (4) USA BOXING’S OFFICIAL RULES PERTAINNG TO MY PRESENT PHYSICAL CONDITION.

SIGNED: ______DATE: ______/______/______

PARTICIPANTS FULL NAME

*SIGNED:______DATE: ______/______/______

PARENT (S) OR GUARDIAN (S) ** REQUIRED IF ENTRANT IS UNDER LEGAL AGE OF 18 YEARS

SIGNED: ______DATE: ______/______/______

BOXER’S COACH (OR OTHER WITNESS)