PLEASE COMPLETE THIS FORM FULLY IN BLOCK CAPITALS

 

Full Name of Applicant: ………………………………………………………………………………...

Date of Birth: ……………………………..

Address:……………………………………………………………………………………....

………………………………………………………………………………………………….

Post Code: …………………………………

Telephone Number: (…………..) ……………………………

Martial Arts History: (Has the applicant ever practised a martial art? If so, please list details including grade achieved, date grade achieved and association/instructor)

……………………………………………………………………………………………………………………………………

 

Medical History: (Does the applicant suffer from any of the following? Please tick in the box provided)

Allergy (ies) [  ] Asthma [  ] Diabetes [  ] Epilepsy [  ] Haemophilia [  ]

Heart Disorder [  ] Hay Fever [  ] Nervous Disorder [  ] Respiratory Disorder [  ] Migraine [  ] Joint/Skeletal [  ] HIV [  ] Other: Does the applicant suffer from any medical conditions/allergies that the club/ coach should be aware of (including any current medication) .........................................................................................................………...…………………….……………………………………
Please provide details of medication that may have be administered: ………………………………………….……………………………………………………………………………………………………………………..
Family Doctor …………………………………………… Doctor’s Tel No  ……………………………........

Emergency contact details:
Name: ……………………………………………………………… Telephone no:  ……………..…………

Alternate Contact Number..................................................................
Relationship to applicant: ……………………………………………………………………………….............

CONSENT (please read carefully)
I agree to my son/ daughter taking part in the activities of the club.

a)     I confirm to the best of my knowledge that my son/ daughter does not suffer from any medical condition other than those listed above.

b)     I consent to my son/ daughter travelling by any form of public transport, minibus or motor vehicle driven by a club coach or any other parent attending, to any event in which the club is participating.

c)     I agree to pay training fees in advance. I understand that the Custom Karate Ltd accept no responsibility for loss, damage or injury caused by or during attendance on any of the clubs organised activities except where such loss, damage or injury can be shown to result directly from the negligence of the Club or the Organisers.

 

Signed …………………………………............. (Parent/ Guardian) Date: ……………………


DECLARATION

 

Applicants Name............................................................................................................

 

At Custom Karate we are always trying to improve the service offered to both you and your child and would be grateful if you could complete the following*:

 

Contact e-mail address that will be used only to keep you up to date with current activities.

                                                                             @

 

 Please name person or persons below who are allowed to pick your child up after class.

 

 

 

 

 

 

*Signed

 

Please Print your name

 

Date

 

 

 

 

Or

I authorise that my child is allowed to leave the class without further adult authorisation.

*Signed

 

Please Print your name

 

Date

 

 

 

 

Or

I authorise the residing Custom Karate Sensei to escort my child to the Barley Hill after school Club (Bash). Not applicable to John Hampden students

 

*Signed

 

Please Print your name

 

Date

 

 

 

 

*You only need to sign one option

 

I declare that the above information is true and correct, and that I will abide by the policies and procedures as laid down by the Custom Karate’s Governing Body. I accept that the practise of any martial art/combat sport involves the risk of serious injury and as a student I have a duty of care/responsibility to myself, my fellow students and masters.

 

Signed: …………………………………………………………….. (Student)

 

Signed: …………………………………………………………….. (Parent/Guardian* of applicant under 18 years)

 

Date: …………………………………………………………………

*It is important that Parent/Guardian explains to anyone they are countersigning for, that each student has responsibilities to both themselves, their fellow student and to the class. This is due in main for the students own safety, but also due to the nature of all martial arts, students are required to maintain the highest standards of safety for both themselves and to their fellow students. This is such an important part of the training that students who are unwilling to take responsibility for themselves may be asked to leave the class.

ONCE COMPLEATED PLEASE EITHER RETURN ELECTRONICALLY or HAND THIS FORM TO THE SCHOOL RECEPTION or YOUR INSTRUCTOR or post DIRECTLY TO CUSTOM KARATE (14 Fanshawe Road THAME OXON OX9 3LF).

 

PLEASE NOTE

We sometimes take photographs or video footage for publicity purposes. These images may appear in our printed publications, on our website, or both. We may also send them to the news media. Before taking any pictures, we need your permission. Please answer questions 1 and 2 below, then sign and date the form where shown. Custom Karate will not identify individual students. This permission only covers photo’s taken in official Custom Karate Classes or Displays. Photos taken outside a Custom Karate Class or Display or by unauthorised private individuals will not be covered by this approval.

 

Please circle: Yes or No

1.     May we use your image(s), or those of your child(ren) if under 18, in our publicity material, including printed publications, videos and our website (delete if this does not apply)?

 

Yes / No

 

Please note that websites can be viewed throughout the world, not just in the United Kingdom where UK law applies. This form is valid for five years from the date of signing.

2.     We sometimes send publicity material about our services, including photographs where appropriate, to the news media, especially the local press. Can we use your photograph, or your child's, in this way?

 

Yes / No

 

 

Signature:……………………………. ...................Date:…………….………… Please print your name in capitals.

 

(and your child's name if appropriate): ……………………………………………………………………………………

 

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