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FULL NAME:________________________________________ AGE:__________
ADDRESS:___________________________________________________________
TEL:_____________________ EMAIL:___________________________________
Do you or have you suffered from any of the following?
Migraine: _____ Epilepsy: _______ Respiratory Problems: _____
Diabetes: _____ Hay Fever: ______ Heart Disorders: __________
Other:________________________________________________________________________________________________________________
Have you ever been convicted of a crime of violence? _______________
What aspects of karate appeal to you the most?
Self Defence: ___ Traditional Art Form: ___ Self Discipline____
Keep Fit: ____ Competitions: ____ Other:___________
How did you hear about this club?_______________________________
I, the trainee understand whilst engaging in the Art of Karate that I must obey the Instructors commands at all times.
In addition to the above, I give my consent as a student of karate to be photographed at any such event and give permission for the photographs to be used in any advertising material including the karate club website.
SIGNED:____________________________________ DATE:____________
PARENT SIGNATURE IF UNDER 18 YRS:_________________________
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