Membership Details

Student First Name

Student Last Name

Date of Birth

Day

Month

Year

Gender

Male

Female

Other

Address

Mobile Number

Home Telephone Number

Email

Next of Kin Full Name

Relationship to you

Next of Kin Phone Number

Previous Martial Arts Experience

Have you practised martial arts before?

Yes

No

Which class do you intend to attend?

Infants

Juniors

Cadets

Adults

Anything else you would like us to know?

Medical Conditions

Declaration

KUROTEN PRACTICAL KARATE RESERVES THE RIGHT TO DECLINE THIS APPLICATION WITHOUT STATING A REASON.

Have you ever been convicted of a criminal offence/had a police caution?

Yes

No

If you fail to disclose all spent and unspent convictions at the point of applying, we reserve the right to withdraw (without notice) your membership without compensation.

Please Tick

I understand that the activity of Karate that I will be participating in holds evident risks as a martial art and whilst every effort is made within the club to ensure safe training, accidents and injury may well happen in the natural course of training.

I agree that all of the information provided above is correct and that I have read and agree to be bound by the Rules and Conditions of Membership. (Read Here)

Photo/Video Release

By participating in Kuroten Practical Karate activities, I hereby give consent that photographs/video image may be taken of me and/or my child for the purpose of advertising, publicity, and/or social media. (Tick to consent, not obligatory)

Is applicant under 18?

Yes

No

Nest Direct Debit Details

Direct Debit Payee Name

Date of Birth

Email Address

Phone

Membership Fee Payment

Membership Fee

Please tick to pay:£26