Application Form

Registration & Disclosure Form
We gratefully ask all students to complete a registration and disclosure form to ensure your instructor and the academy are aware of any relevant medical information and contact details prior to training. If you have any questions regarding this form, please speak directly with your instructor before commencing any form of training. Please write in Capital Letters.
Date
Title
Name

First NameLast Name
Which Activity are you interested in?
TIGHS Only

Year 7Year 8Year 9
In order to Gift aid your donation you must tick the box below. I want to Gift Aid my donation for this session to the charity Z’s Defence Academy(1194054) & any donations I make in the future or have made in the past 4years.

YesNo
We are currently working with the University of Central Lancashire to research the impacts of our Self-Defence Course on your Mental Health & Wellbeing. If you are aged over 18, we would appreciate it if you would participate in this by completing a series of anonymised questionnaires before and after your 6-week course. To find out more about how you can get involved, please tick the box so the research team can send you further information.

YESNOI am under 18 & not doing the Self Defence Course
Have you achieved a grade C or above in Maths or English GCSE?

Maths - YesMaths - NoEnglish - YesEnglish - No
We provide complimentary taster sessions for organisations, corporations, and charities. Please take a moment to answer the questions below. Name of Workplace
Contact of work place
Please enter a valid phone number.
Email for workplace
Do you have any Allergy?
Are you a carer ?

Yes AdultYes Under 18'sNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
Communication

We would like to add you to our group Facebook Group/ Wats App Chat / Email Campaigns so you can quickly and easily communicate with the instructor and fellow students (i.e: with notices regarding classes, to let us know about attendance etc). For more personal matters we would appreciate your e-mail address, so we can drop you a line directly and in confidence.
Ethnic Group
Phone Number

Area CodePhone Number
Email
example@example.com
Photography & Videography Consent

From time to time we like to share photos or videos of our students with the rest of the club. This may be via Facebook, Instagram or other social media platforms. We may also like to use photos from training to help advertise our class to others – for example, via our website.
Are you happy to be included in photography, and for it to be used as described above?

YESNO
Club Rules & Disclaimer

We’re keen to create a safe, enjoyable space where everyone is free and able to learn martial arts/self-defense without harassment or intimidation. Our Academy operates a zero tolerance on bullying or any such harassment during or outside of training. Your instructor is here to keep you safe and help you learn – we ask that you please show respect and listen carefully to instructions when given, as they are for your own protection. Training within our academy is done entirely at your own risk, in conjunction with our assumption of risk form which you must read before training. We ask that you operate a common-sense approach – it’s combat training, you’re not made of metal – you might get hurt. We’ll do all we can to protect you but injuries can occur from time to time. You agree to undertake training at your own risk and must ensure you have the relevant insurance, license, membership, personal accident and liability insurance. Talk to your instructor who will provide you with further information about the above.
Please confirm you are happy to agree to our Academy rules and disclaimer

Clear
Medical Disclosure

This is really important
We need to know if you have any past or current medical conditions, injuries or medication that you might need to disclose to your instructor.

This is stored in the utmost of confidence and will be treated with sensitivity. Our instructor needs to know if there are any injuries or conditions present that might heighten your risk of injury or harm when undertaking different exercises and drills.

Please talk with your GP before training with us if you have any concerns or any medical conditions past or present to ensure it is safe to proceed.
Medical Conditions and injuries
Has your doctor ever said that you have a health condition and that you should only do physical activity recommended by a doctor?

YesNo
If you ticked yes please elaborate here
Do you currently or previously have any history of the following conditions? (This information will help to ensure that your trainer can recommended the best and safest practice for you

AnxietyAsthmaArthritisBipolarBreathing DifficultiesCancerChronic FatigueChronic PainDepressionDiabetesDizziness/FaintingEpilepsy/SeizuresEating DisorderGlaucoma/Detached retinaMigrainesHeart ConditionLow/high blood pressureOsteoporosisPanic/Anxiety attacksPTSDComplex PTSDSciatica/Back conditionNone of the above
Do you have any disabilities which we may need to be aware of in order for you to take part in the sessions safely? (This information will help to ensure that your teacher can recommended the best and safest practice for you.)

YesNo
If yes please Specify
Are you currently taking part in any other forms of treatment? (e.g. medication, counselling/therapy, physiotherapy etc). If so, please provide details
Have you been hospitalised for any medical reasons in the last 12 months (e.g. surgery/psychiatric treatment?).

YesNo
If yes, please specify
Have you participated in physical activity before? Is there anything you would like us to be aware of about your experiences, positive or negative?
Please share any further any information you feel is relevant here:
Pregnancy

Unfortunately, our classes are not suitable for anyone who is, or may be, pregnant due to the nature of impact and contact. We won’t ask you to confirm you’re not pregnant – but please talk to your instructor now, or in the future, should this become relevant.
Are you Pregnant? Unfortunately, our classes are not suitable for anyone who is, or may be, pregnant due to the nature of impact and contact. We won’t ask you to confirm you’re not pregnant – but please talk to your instructor now, or in the future, should this become relevant.

YesNo
EMERGENCY CONTACT / NEXT OF KIN

Please indicate who we should be contacting in the unlikely event of an incident
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Relation
Signature
By signing this form I declare that the above information is true and correct. I certify that I have and will answer all questions to the best of my ability and that I have not and will not withhold any information that would unfavourably affect my application to become a student at the Academy. I accept that, whilst all reasonable care is taken, the instructors are not legally responsible for any accidents or injuries which may occur whilst I am training in the class. I understand that misrepresentations or omissions may be cause for my immediate rejection as a student with Z’s Defence Academy.

I am medically fit to undertake intensive physical training.
Signature

Clear
Name

First NameLast Name
Date
UCLAN ONLY

STUDENTSSTAFFTASTERCOURSE
Should be Empty:

Registration & Disclosure Form

Communication

Photography & Videography Consent

Club Rules & Disclaimer

Medical Disclosure

Medical Conditions and injuries

Pregnancy

EMERGENCY CONTACT / NEXT OF KIN

Signature