Submit to: Mosman Martial Arts Academy - Shop 12, 200-212 Military Rd. - Neutral Bay, NSW 2089. Tel. 0415 951 366 ... Ph
Membership Registration Form - Page 1 of 2 PLEASE COMPLETE ENTIRE FORM AND PRINT CLEARLY IN BLOCK CAPITALS
MEMBERSHIP REGISTRATION FORM
A CEducate A DYourESpirit MY 1987
Submit to: Mosman Martial Arts Academy - Shop 12, 200-212 Military Rd. - Neutral Bay, NSW 2089 Tel. 0415 951 366 ♦ Email -
[email protected] ♦ Web - www.martialartsacademy.com.au
Student’s Full Name: Student’s Preferred Name: Mother / Guardian’s Name: Father / Guardian’s Name: Street Address: Suburb
Postcode:
Home Phone:
Work Phone:
Mobile: Email 1: Email 2: Student’s Occupation: Person to contact in case of an emergency: Name:
Date of Birth:
Age:
Phone No:
Do you or have you ever suffered from any medical condition or injury that may affect your ability to train? ........... Yes / No e.g. asthma, high blood pressure, insulin-dependent diabetes, previous knee, back injuries or learning disability etc. If YES, please specify: .................................................................................................................................................................................................... ........................................................................................................................................................................................................................................
Are you on any medication/s that may affect your ability to train? ...............................................................................................Yes / No E.g. asthma inhaler, blood pressure medication, insulin etc. If YES, please specify: .................................................................................................................................................................................................... ..........................................................................................................................................................................................................................................
NB: Should any of the information specified in relation to injury or illness listed above change, the onus is on the student to inform the instructor as soon as they become aware of this, and prior to taking part in any further training sessions. Always check with your doctor before beginning any course of rigorous activity.
To assist us in promotion, can you please advise how you came to hear about MOSMAN MARTIAL ARTS ACADEMY? Newspaper advertisement, list paper: .................................................. School newsletter, list school:.................................................................. Mailbox Leaflet drop? .......................................................................... Demonstration where?............................................................................. Recommended by? ............................................................................... Internet website, List?.............................................................................. Other please specify:................................................................................................................................................................................................
In order to assist you in achieving your goals can you please specify what benefits you want to achieve: Please circle any of the following that apply: Focus Discipline Coordination Endurance Self Esteem Self confidence Fitness Self defence Weight control Social outlet Please specify if any other reason: ...........................................................................................................................................................
Have you participated in any form of martial arts before?................................................................................................... Yes / No If yes, please specify what style, where you trained, when and what level you attained: ....................................................................... .................................................................................................................................................................................................................. I acknowledge that all information provided by me is true and correct at the time of completion and should this change in the future I will immediately advise Mosman Martial Arts Academy of any changes.
Signature:.................................................................................................................................. Date: ...................................................................... Note: if student is a minor (under 18 years of age) then a parent or guardian must sign this form.
Membership Registration Form - Page 2 of 2 PLEASE COMPLETE ENTIRE FORM AND PRINT CLEARLY IN BLOCK CAPITALS
A CEducate A DYourESpirit MY
MEMBERSHIP FEES: Joining fee: $35 per student/family (one off payment) Yearly insurance: $45 per student/family (first year only, we pay every other year) Karate uniforms: $50 per student or you can bring your own Kickboxing gloves & hand wraps: $55 per student or you can bring your own
Kids Karate Classes Small Steps $20/class payable per school term once a week Basic Plus $18/class payable per school term twice a week Fast Track ............................................
1987
Adults Kickboxing/ Karate Upgrades/Renewals/Notes Women’s Self Defence Small Steps $100 ($25/class) 4 classes a month Basic Plus $180 ($22.5/class) 8 classes a month Fast Track ............................................ ............................................ ............................................ ............................................ ............................................
............................................ ............................................ ............................................ ............................................ ............................................ ............................................ ............................................ ............................................ ............................................ ............................................
Any missed classes may be made up in subsequent weeks, but no refund will be given for non-attendance. All payments are nonnegotiable and must be up to date. Classes run throughout the whole year except from public holidays and a few days after Easter, Christmas and New Years’s Day.
Terms and conditions I understand that the school obligates itself to furnish me with competent instructor and suitable facilities for teaching lessons. Qualified instructors trained in the procedures and traditions of the Martial Arts supervise all class sessions. The private tuition rate is $75.00 per hour, however, a substantial discount has been provided to me by virtue of enrolling in a regular course/class. The Student hereby declares that he/she is physically fit to receive and participate in the prescribed course of instruction, and faithfully complies with all the rules and regulations of the School and the traditions of the Martial Arts. I further understand that as a payer I am purchasing enrolment at this school for the students listed on this membership form. Enrolment provides the students with the opportunity to attend the specified number of classes. I understand and agree that Martial Arts is dangerous and that the school will not be held liable for injuries, damages etc. not caused by or resulting from the negligence of the owners, operators, employers or persons in charge of such establishment. Photo, video, audio release. The buyer agrees that the school may take photographs and may make video and audio material of student’s classes and schools events, and that these materials may be used for display, promotion and/or advertising, or sold for profit, and the student hereby waives any compensation to which they may otherwise be entilted for appearing in such materials. The school understands the importance of, and is committed to complying with the Privacy Act (1988) and the National Privacy Principles. The school only collects information that is necessary to effectively manage your tuition payments and provide you with Martial Arts lessons.
Consent Form I, ................................................................... do hereby accept the above conditions and consent to my participation in training at the Mosman Martial Arts Academy.
Signature:............................................................................................................. Date: ......................................................................
Consent Form for Student under 18. The following must be completed by parent or guardian. I, .................................................................. being the parent/guardian of .................................................................. do hereby accept the above conditions and give permision for him/her to become a member and to practise at the Mosman Martial Arts Academy.
Signature:............................................................................................................. Date: ......................................................................
