Name

Email Address

Date of birth

Address

Post code

Telephone number

Licence number

Grade

Do you or student suffer from any medical conditions? Do you or student suffer from any medical conditions?YesNo

If yes to the above please give brief description

Are you taking any medication? Are you taking any medication?YesNo

Have you ever been convicted of a crime of violence? (adult students)? Have you ever been convicted of a crime of violence? (adult students)?YesNo

I understand that the above information is true and correct. I will inform Worthing Karate Academy immediately if any of my circumstances, as stated above, change during the course of my membership. My membership is renewable yearly. I do not hold the Worthing Karate Academy or Chief Instructor or Instructors responsible for any injury or disease or damage to property caused by accident arising of out of training. I have consulted my doctor and know of no medical reason why I should not commence training within the Martial Arts. I have read and understood the Dojo(club) Rules and Training Conditions. I ACCEPT THAT THE TRAINING OF KARATE INVOLVES PHYSICAL CONTACT AND THAT THERE IS A RISK OF INJURY. I understand that the above information is true and correct. I will inform Worthing Karate Academy immediately if any of my circumstances, as stated above, change during the course of my membership. My membership is renewable yearly. I do not hold the Worthing Karate Academy or Chief Instructor or Instructors responsible for any injury or disease or damage to property caused by accident arising of out of training. I have consulted my doctor and know of no medical reason why I should not commence training within the Martial Arts. I have read and understood the Dojo(club) Rules and Training Conditions. I ACCEPT THAT THE TRAINING OF KARATE INVOLVES PHYSICAL CONTACT AND THAT THERE IS A RISK OF INJURY.YesNo