New Member Registration Form
Member Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Phone Number
*
Format: 0000000000.
E-mail
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
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Health Declaration
Are you prescribed drugs which may impair reaction time or judgement?
*
Yes
No
If yes, what drugs?
Have you suffered any incapacity requiring medical attention in the past 12 months?
*
Yes
No
If yes, give details:
Name and identify any psychical impairments, injuries or medical condition that currently affect you:
Are you aware of any health problem that you have that, in the interests of your safety, the club should be advised of?
*
Yes
No
If yes, please describe:
Emergency Contact
Name
First Name
Last Name
Relationship to you
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Martial Arts History
Have you studied martial arts before?
*
Yes
No
What martial arts style have you studied?
What grade did you achieve?
How many years did you study?
What was the name of your instructor?
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Exclusion of Applicant
Have you ever been excluded from Martial Arts in the past by a medical practitioner or any other person or entity or a Martial Arts Club?
*
Yes
No
If yes, provide details:
Agreement
I am completing this form for:
*
Myself
As a guardian
I have read and understood the terms of the terms and conditions or if I did not understand the terms and conditions I requested an independent person to explain them to me. I certify and decree that all of the information contained in the declarations above is true and accurate.
*
Submit
Submit
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