Please enable JavaScript in your browser to complete this form.Name *FirstLastMembership Type *$60/ 6 month or $100/year membership (Ages 10 – 17)$120/ 6 month or $200/year (Ages 18 – 25)OtherSexMaleFemaleBirth date *xx/xx/xxxxMailing address *City *State *Zip code *Phone number *Email *Do you consent to receive information from Haverhill Inner City Boxing Club, Inc., via email?YesNoEmergency contact name: *Emergency contact phone: *Submit
