International Student Membership Registration Form

International ShinKenDo Organisation Japan 国際新剣道機構ジャパン
Student Name
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth date

DayMonthYear
Gender

MaleFemale
Current Grade
Instructor Name

First NameLast Name
Dojo location
Date

MonthDayYear
Date
Parent/Guardian Information (if under 18)
Name

First NameLast Name
Mobile Number

eg 021Phone Number
E-mail
example@example.com
Country
Alternative Emergency Contact
Emergency Contact's Name

First NameLast Name
Mobile Number

eg 021Phone Number
Do you suffer from any asthma, allergies, or any other medical condition? If yes, please describe.*
Additional Information
Do you have a criminal record

Please tick if YesPlease tick if No
Decleration

I understand that ShinKenDo allied activities carry a risk of injury and that the International ShinKenDo Organisation Japan are not responsible for any injuries or loss suffered as the result of participating in these activities.
I shal not hold the instructor assistant instructor or any Organisation committee for any inuries suffered

Medical Authorization

In the event of an injury or medical emergency, I allow International ShinKenDo Organsiation to provide first aid, arrange transport to a medical facility, and authorise emergency treatment as recommended by a doctor for the students named above.

I understand that all reasonable efforts will be made to contact the students parent and/or emergency contact if an injury or medical emergency occurs.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Please Sign Here
Payment
Please complete the details below
Please state if renewals or membership application.

NOTE:
Membership allows students to sit grading exams.
Non Memberships wll refrain students from being tested or promoted for belt rank
please renew your membership yearly
Membership yearly fee (€12) (¥1000) (£10)

Membership Payment*

EURDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

International ShinKenDo Organisation Japan 国際新剣道機構ジャパン

Additional Information