LONDON BOXING New BRC1 & Duplicate Application Form Please complete all the fields below and mark one character per square, letters in CAPTIALS. Once completed, return the form to the London Medical Registrar along with a photocopy of ID that proofs date of birth of boxer (passport, driver’s license, birth certificate etc), x2 printed passport photographs and if sent via post, a self- addressed stamped envelope to the below address. Reggie Hagland - Islington Boxing Club - 20 Hazellville Road – London - N19 3LP. New BCR1’s will be drawn up ASAP but during busier periods this can take up to 14 days to process. Any application for a duplicate BCR1 will take 30 days to finalise, allowing time to investigate the boxers record and draw up a new medical card. A full medical is required for all duplicate BCR1’s and a fee of £10 must be paid before a duplicate BCR1 can be processed. Applications for BCR1’s will NOT be accepted without this form being fully completed and signed by the relevant persons. All boxers must also be registered & paid for on the Vault before applying for a BCR1. These are minimum details required for the release of medical cards. BCR1’s will not be stamped until a full medical is completed by a registered England Boxing doctor. First Name: Surname: Date of Birth (DD/MM/YYYY): Nationality: Address: Town/City: Post Code: Weight (KG): f f f ff f f Telephone Number: Club: Email Address: NEXT OF KIN INFORMATION: FOR BOXERS AGED 18 AND UNDER Name of Next of Kin: Telephone No of NOK: Relationship to NOK: f f f ff Previous Amateur Boxing Experience: Other Combat Experience (White Collar Boxing, Kick Boxing, Muay Thai, MMA etc): WINS LOSES I can confirm that the above information is correct including my stated previous experience in either amateur boxing or any other combat sport(s). I understand that any false declaration of previous experience could warrant a suspension/exclusion from England Boxing. The Hon. Sec/Head Coach of the club should try their upmost to ensure that the above is true but ultimately it is always the boxer who is responsible for the true declaration of experience. Signed (The Boxer):……………………………………………… Signed (Parent/Guardian of Boxer if U18):……………………………….. Signed (Hon. Sec/Head Coach):………………………………………. Please state name & role: ………………………………………………………… .