L&T JJC Induction Form

Student Induction Form

To request membership/insurance with World Ju-Jitsu, Ireland as a Lurgan & Tandragee JuJitsu Club member
Start Date*

DayMonthYear
Number of participants*
Class frequency:
- Full Name*
- Date of birth*
  
  DayMonthYear
- Medical Information
- Please state any medical conditions which may be aggravated by exercise
- Heart TroubleAsthmaHigh Blood PressureSeizuresChest PainsHIVNervous DisordersHerniaMigraineADD / ADHDHaemophiliaBack PainDiabetesHay FeverFaint / Dizzy Spells
- Allergy
- Other
- Full Name*
- Date of birth*
  
  DayMonthYear
- Medical Information
- Please state any medical conditions which may be aggravated by exercise
- Heart TroubleAsthmaHigh Blood PressureSeizuresChest PainsHIVNervous DisordersHerniaMigraineADD / ADHDHaemophiliaBack PainDiabetesHay FeverFaint / Dizzy Spells
- Allergy
- Other
- Full Name*
- Date of birth*
  
  DayMonthYear
- Medical Information
- Please state any medical conditions which may be aggravated by exercise
- Heart TroubleAsthmaHigh Blood PressureSeizuresChest PainsHIVNervous DisordersHerniaMigraineADD / ADHDHaemophiliaBack PainDiabetesHay FeverFaint / Dizzy Spells
- Allergy
- Other
- Address*
  
  Street Address
  
  Street Address Line 2
  
  Town / CityState / Province
  
  Postcode
- Phone*
- Mobile
- Email Address*
  example@gmail.com
- Emergency Contact
- Contact Name*
- Emergency Contact Phone *
- Relationship to participant*
- YesNo (If you do not consent please make your instructor aware of this)
- YesNo
- If yes, please give details
- I agree to abide by all rules, notices and terms of membership and, at all times, uphold the traditions and spirit of Martial Arts. It is accepted and understood that participation in the Martial Arts carries the risk of injury, as in all contact sports. I understand that the WJJF Logo, its trademarks and its designs can only be used with the prior written consent of that organisation. I declare I am fit to train in the Martial Arts.
- Signed*
- Finally, how did you hear about us?
- Calculation
- Membership Summary*
  prevnext( X )
  Monthly membership
  Monthly membership for all participants included in submission.
  
  GBP for each month
- Should be Empty:

Student Induction Form

Medical Information

Medical Information

Medical Information

Emergency Contact