BUSHIDO KARATE CLUB. Mahon Club: Mahon Community Centre, Avenue De
Rennes, Mahon, Cork City, Ireland. Douglas Club: Ballet Theatre of Ireland, ...
BUS
O K A R AT E C LU B
HID
BUSHIDO KARATE CLUB
Ballet Theatre of Ireland, Douglas Court Shopping Centre, Douglas, Cork City, Ireland. T: 087 6307006 (Sensei Aaron Kenneally) - E:
[email protected] - W: www.bushidokarate.ie
MEMBERSHIP REQUEST FORM We will require 3 Passport size photographys for your official SKIF Ireland Documents such as SKIF Ireland Grading Book SKIF Ireland Licence SKIF Ireland Grading Record If you would prefer we can take a photo at the club which will be used on the above forms.
PLEASE ATTACH A PASSPORT SIZED PHOTO OR WE CAN TAKE A PHOTO AT THE CLUB
STUDENT DETAILS STUDENT DATE OF BIRTH
STUDENT FULL NAME HOME ADDRESS
HOME TELEPHONE EMAIL ADDRESS
IMPORTANT: Please Provide a mobile number for receiving SMS training and fee reminders
MOBILE
Has the student ever taken part in a martial arts class or any other combat sport? If yes please state details
MEDICAL CONDITION DISCLOSURE Has the student ever had a previous sporting injury or is the student suffering from any pre/existing medical injury/ condition that could affect training. If yes, did this result in any legal insurance claims, hospitalisation or medical treatment? If yes please state details. Please note that failure to disclose any relevant information can cause your membership request to be refused or cancelled at any time in the future should any false information be discovered. Please note that this does not affect your statutory rights. Please note that Bushido Karate Club prides itself on your personal safety and therefore it is essential that all pre/existing conditions be addressed at point of joining to comply with insurance regulations.
PLEASE ATTACH A PASSPORT SIZED PHOTO OR WE CAN TAKE A PHOTO AT THE CLUB
EMERGENCY NEXT OF KIN / PARENT / GUARDIANS DETAILS. ALL STUDENTS MUST COMPLETE THIS SECTION. WE HOPE TO NEVER HAVE TO USE THESE DETAILS EVER. PLEASE ATTACH A PASSPORT SIZED PHOTO OR WE CAN TAKE A PHOTO AT THE CLUB
PARENT / GUARDIAN FULL NAME
RELATIONSHIP TO STUDENT
HOME ADDRESS
HOME TELEPHONE
MOBILE TELEPHONE
If the student is less than 18 years of age a parent / guardian signature is required and also the same parent / guardian must be listed above as the next of kin details. Please note that by signing you are stating the following: Bushido Karate Club is not responsible for any injuries suffered while on premises and that you are aware of the risks in taking part in a karate class. This form is only requesting to be accepted as a member and full membership is only granted on approval by the head Instructor.
PARENT / GUARDIAN SIGNATURE
DATE
