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.

  • TIGHS Only
  • 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.
  • 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.
  • Have you achieved a grade C or above in Maths or English GCSE?
  • Format: (000) 000-0000.
  • Are you a carer ?

  • 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.
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  • 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?

  • 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.

  • 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?
  • 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
  • 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.)
  • Have you been hospitalised for any medical reasons in the last 12 months (e.g. surgery/psychiatric treatment?).

  • 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.

  • EMERGENCY CONTACT / NEXT OF KIN

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

  • UCLAN ONLY
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