Affiliate Application Form

Step 1 of 4

Requested Affiliate Location Name(Required)

Rock Steady Boxing(Required)

Location name approval subject to RSB discretion

I understand that my application's approval is at the discretion of RSB Staff.(Required)

Yes

Please select your desired in-person training date/location:(Required)

Class Location Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Affiliate Mailing Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Affiliate Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Affiliate Owner Info

Affiliate Owner Name:(Required)

Affiliate Owner Email(Required)

Affiliate Owner Phone Number(Required)

Main Contact Info

Main Contact Name(Required)

Main Contact Email(Required)

Main Contact Phone(Required)

(this phone number will appear on your affiliate website)

Coaches Trained or To Be Trained

Trainee Name(Required)

T-Shirt Size(Required)

Trainee Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trainee Name

T-Shirt Size

Trainee Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trainee Name

T-Shirt Size

Trainee Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Trained coaches

Operational

Are you renting space to host your program?(Required)

Yes

Facility Owner Name(Required)

Facility Owner Email(Required)

Facility Owner Phone(Required)

Educational Background & Professional

By way of more formal education and athletic certifications, at least one of the below credentials is required for all Coaches and Head Coaches. These are not required of Assistant Coaches or Volunteers— • Hold and maintain a professional certification as a Personal Trainer through the American College of Sports Medicine (ACSM), the National Academy of Sports Medicine (NASM), OR another nationally accredited organization recognized by the RSB Board for this purpose; • Hold and maintain licensure in the profession of Physical Therapy, Occupational Therapy, Speech Therapy, or Athletic Training under the issuing authority of any State or Province; • Hold a formal undergraduate degree from an accredited academic institution in fitness or health-related field. (i.e., Kinesiology, Physiology, or Exercise Science)

Specify: (Y or N; Name, position, & certification/degree):

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