Mathieu Karate Academy Student Registration Form

Mathieu Karate Academy (M.K.A) Student Registration Form

We are delighted you have chosen to enrol with M.K.A. Please fill in the student details below - one completed form per student. Any questions or concerns, please contact Sensei Ross on 07944 322 166 or mathieukarateacademy@gmail.com. Thank you.
CLASS INFORMATION

Days: Thursdays

Beginners: 6:00pm- 7:00pm

Intermediate: 7:00pm- 8:10pm

Location: Forest Gate School. Forest Street. E7 0HW.

Cost: £40 per month

Registration / Annual Licence Fee: £35 per year
Today's Date*

DayMonthYear
Date of first session (Please select date of your first session)*
Date of first trial lesson*
Student Details

Everything we need to know about our student.
Are you an existing M.K.A student?*

YesNo
What is the student's current belt?*
Student Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*
Nationality*
Address*

Have you ever suffered from the following?*

	Yes / No
Respiratory Problems (Including Asthma)
Heart Disorders
Diabetes
Epilepsy
Migraine

Any other health problems?
Student Height (cm)*
This is to ensure the correct Karate Suit is supplied
Previous Martial Arts Experience with another club*

YesNo
Please give details of previous martial arts experience
Contact Details

Parent / Guardian contact details if under 18
Parent / Guardian Full Name*

First NameLast Name
Email*
Contact Number 1*
Contact Number 2
Relationship to Student*
We have a WhatsApp group dedicated to keeping our students' parents up to date with announcements and notifications. Are you happy for your number to be added to this group?*

YesNo
Additional Comments
Declarations

Please read through and confirm you agree with the terms and conditions below.
Payment is due by direct debit on the 2nd of every month. Once registration is complete, you will be sent a direct debit form to fill in. Fees cannot be refunded or 'carried over' for missed sessions.*

I understand and accept the above payment terms.
I understand that, whilst all reasonable care is taken, M.K.A instructors are not legally responsible for any accidents or injuries which may occur whilst training under their leadership. I am / my child is medically fit to undertake intense physical training.*

I understand and accept the above terms & conditions.
I hereby give Mathieu Karate Academy (M.K.A) permission to use any still and / or moving image being photographs, audio or video footage showing the person named above for any advertisement, marketing or promotional material created and utilised by M.K.A.*

I understand and accept the above terms & conditions.
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Mathieu Karate Academy (M.K.A) Student Registration Form

Student Details

Contact Details

Declarations