SEMKA Licence Form

SEMKA Licence Application Form

All members must hold an up-to-date Samurai Enlighten Mushin Karate Academy (SEMKA) Licence / Record Book
Full name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Phone Number*

+44(0)1234567890
EMERGENCY Number
Date of Birth*

DayMonthYear
Provide us a "passport" style photo of yourself:*

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"Passport" Photo

Please select a recent, clear, 'passport' style photo of yourself.
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Please ensure your photo is in a 'passport' style, that is: clear face, recent, properly framed and lit with a neutral background.

Photographs are important for identification purposes for registration and processes
for open grading, assessments and competitions, etc.

Please ensure your picture is up to date in your licence. If you do not have a fairly recent portrait photograph in your licence you may be refused to be graded or accepted into competitions.
Email

Confirmation Emailexample@example.com
* By supplying your email address you are entering into an agreement that you
would like to receive SEMKA related information.

If you do not wish to receive this information this can be cancelled at any time.
Association Group / Club*
Signing instructor's email address (required for verification)*
Leave default unless otherwise told
Present grade (if ungraded, enter "Ungraded", otherwise Kyu/Dan grade)*
Start date

DayMonthYear
Date
Have you ever practiced martials arts before, if so, please give details:

SAMURAI ENLIGHTEN MUSHIN KARATE ACADEMY

IMPORTANT INFORMATION & CONDITIONS - PLEASE READ BEFORE APPLYING
IT IS YOUR RESPONSIBILITY TO HAVE A VALID LICENCE & INSURANCE
IT IS THE STUDENT’S RESPONSIBILITY TO SEND THE LICENCE APPLICATION FORM FULLY COMPLETED DIRECTLY TO THE LICENCE OFFICE

***

Insurances £10m Club Liability, Public Liability & Person to Person Liability, £10m Instructor Liability (where applicable) within a valid Licence is for all traditional Wadoryu training and related activities organised by the British Wado Federation. Cover does not include training outside of British Wado Kai/Federation/S.E.M.K.A.. Students are also uninsured to train in Sport Karate, MMA, kick-boxing, training with [or use] of metal-bladed weapons, etc. An Instructor who allows, promotes, encourages, or has knowledge of any of his membership involved within these ‘inadequately insured’ activities, will be considered ‘Negligent & Liable’.
If unsure, please contact our main Insurance Company. For UK Personal Accident Cover, and/or Freelance Instructor Insurance Cover, please contact our main insurance company.

Applications from other Wado Organisations outside of SEMKA
Grades registered within your existing karate licence will be 'automatically' transferred to your New S.E.M.K.A. Licence upon acceptance; Please include your present Licence for SEMKA records. Your Instructor will continue your grade commencement once you are in receipt of your new licence and are fully conversant with the requirements for progression.

Late Renewals - Firstly. It is the sole responsibility of the individual to keep their insurance, licence, membership up to date and valid. Secondly. It is considered 'negligent' for instructors to allow students to train without adequate insurance.

Replacement Licence Books – To replace a Licence Book, that has been lost or damaged, you must use this form. Replacements cost £8.00. Only your recent ‘registered’ grade will be entered on the Licence Book. YOU ARE NOT INSURED TO TRAIN IF YOU DO NOT POSSESS A VALID UP TO DATE LICENCE.

United Kingdom National Benefits Insured: General Third Party Indemnity, Public Liability and Member to Member Liability; £10,000,000. For Full Synopsis, please refer to Master Policy.

BWF Insurance Covers all ages.

A S.E.M.K.A. Licence includes: 1. Registration & Membership to British Wado
Federation/International Wado Federation. 2. UK Person to Person and Public Liability Insurance cover for £10,000,000. 3. Personal grade record log. 4. SEMKA Badge

Due to the high turnover of student memberships in martial arts it is usually considered that if a martial-arts licence has expired it is normally due to the result of the individual Terminating training & membership etc. A student who allows his/her licence to expire will result in the following:
1. Registration card is destroyed after 3 months expiry.
2. Grade records destroyed after 3 months expiry.
3. Person to person liability insurance cover becomes invalidated at time of expiry.
4. Membership terminated at time of expiry.
Once reapplication has been accepted all records are replaced.
CONFIDENTIALITY: ALL INFORMATION RECEIVED WILL BE FOR OFFICE USE ONLY

Licencing Options
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New Licence - StudentA new SEMKA student Licence
£30.00



Replacement Licence Book
£8.00



Karate Gi (Suit)These are Blitz Cotton Student Karate Gi - 7oz. Ideal first gi for students. Trousers have an elastic/tie waistband. White belt included. 100% cotton 7oz at a club price. Once ordered it will be given to you child in the karate class at the school . The badge that came with the licence book can be placed on the left side of the jacket, above the heart.
£16.00 Size / HeightQuantity
Item subtotal:£0.00



Total

£0.00
If paying by bank transfer, please use the following details:

Bank Barclays Bank
Account Name SEMKA
Sort Code 20-42-58
Account Number 30349127

Important: Please email/send receipt or proof of payment to semka@btinternet.com

If paying by cheque, please hand it directly to your instructor.

PLEASE ENSURE STUDENT NAME IS ON THE BACK OF THE CHEQUE
BACS Reference Used

Have you ever been convicted of a crime of violence?*

YesNo
If YES we will contact you for details.
Do you accept that the practice of a combat-art or contact-sport involves the risk of serious injury?*

YesNo
Do you suffer from any medical condition/s?*

YesNo
If yes, please include information relevant to your conditions, INCLUDING whether you are taking any medications.
It is important to ensure that your instructor is aware of any medical condition.
ALL applicants are heavily advised (especially over the age of 40) to have a Medical
Examination BEFORE commencing into any physical activity related to the Martial-arts.
I understand that the above information is true and correct. I will inform S.E.M.K.A. immediately if any of my circumstances, as stated above, change during my membership. My membership is renewable yearly.
I have consulted my doctor and know of no medical reason why I should not commence training within the Martial Arts.
I have read and understood the Dojo (Club) Rules and S.E.M.K.A. Training Policy and Conditions
Applicant Signature (Parent / Guardian if under the age of 18 years)*

Clear
Name of Signature*

First NameLast Name

Should be Empty:

SEMKA Licence Application Form