Student Analysis/Membership Form v0.3

Student Declaration Form
Who is the form being completed for?*
When completing this form on behalf of a child we also need parent/carer/guardian details, so please ensure you complete the 'Your details' section as well as details about the child.
When completing this form on behalf of children we also need parent/carer/guardian details, so please ensure you complete the 'Your details' section as well as details about the children.
Your details
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Post code
Mobile Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Email*
example@example.com
Martial art preference*
Previous martial arts experience
Child's details
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Date
Relationship to you*
Is the child's address and contact information the same as yours?*
Address*

Street Address

Street Address Line 2

CityCounty

Post code
Mobile Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Martial art preference*
Previous martial arts experience
Second child's details
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Date
Relationship to you*
Is the child's contact information the same as yours?*
Address*

Street Address

Street Address Line 2

CityCounty

Post code
Mobile Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Martial art preference*
Previous martial arts experience
How soon would you be interested in beginning your two week free trial?*

MonthDayYear
Date
Class Choices
Kobudo (from age 8)

Mondays 1930 hrs
Taekwondo - Mondays

Age 6-9 1700 to 180010 and up 1815 to 1915
Kickboxing - Tuesday

Age 4-6 1630 to 1715Age 7-9 1720 to 1815Age 10-13 1825 to 1925Senior 1930 to 2030
Karate - Wednesday

Age 7-9 1720 to 1815Age 10-13 1825 to 1925Senior 1930 to 2030
Kickboxing - Thursday

Age 4-6 1630 to 1715Age 7-9 1720 to 1815Age 10-13 1825 to 1925
Senior 1930 to 2030 Class Full
Karate - Saturday

Age 4-6 0910 to 0955Age 7-9 1000 to 1055Age 10-13 1105 to 1205
Senior Karate/Kickboxing - Saturday

1215 to 1315
Physical health
For Health and safety purposes we need to record information on any disabilities. We would be grateful if you would complete the next section. The Disability Discrimination Act 1995 defines a disabled person as anyone with a physical or mental impairment, which has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-day activities.
Do any of the participants have a disability?*
If yes, what is the nature of the disability?

Visual impairmentHearing impairmentPhysical disabilityLearning disabilityMultiple/otherSpecial Educational Needs
If disclosing for more than one participant, or you have selected 'multiple/other', please provide details below and include the names and disabilities as applicable:
Do any of the participants have...
Any conditions requiring medical treatment and/or medication? *
If yes please specify, with names and medical treatment and/or medication as applicable:
Any allergies? *
If yes please specify, with names and allergies as applicable:
Please provide any further information you feel is necessary
Marketing research
How did you hear about us?*

Internet searchFacebookInstagramRecommendationPassing byOther
Social media consent
I consent to myself /child's involvement in Martial Arts activities being photographed or videoed and for these imagesbeing displayed/viewed.*

Within the Martial Art premises eg. NoticeboardsIn promotional material eg leaflets, local magazineAcademy websiteFacebook academy pageNone of the above
I consent to receiving marketing information from Yorkshire Martial Arts via*

EmailTextBothNeither
Yorkshire Martial Arts Ltd will also, where necessary, send you service emails and/or texts to ensure you are kept up to date with the latest information. Your selections above do not extend to these types of communications. However, we promise only to send information that is necessary for you/your child to know as part of your/their journey with us.
Do you consent to being added to:

Student information WhatsApp groupStudent Email Distribution Group
Rules of participation
- Yorkshire Martial Arts Ltd and its employees/agents shall not be liable for any loss, damage or theft of property unless caused by their negligence
- Yorkshire Martial Arts Ltd and its employees/agents shall not be responsible for any personal injury, death or illness unless caused by their negligence
- Yorkshire Martial Arts Ltd and its employees/agents shall not be responsible for any personal injury, death or illness caused by the failure of any person to follow Yorkshire Martial Arts Ltd Rules of Participation
- By participating in martial arts, the Student agrees that he/she is in good physical condition and knows of no medical reason why he/she should not take part
- By taking part in martial arts the Student recognises that he/she is taking part in a highly physical contact sport whereby injury may occur during the normal course of that physical contact
- All Students must properly warm up prior to classes
- Proper protection must be worn during all fighting
- Failure to follow the Rules will result in disciplinary procedures as deemed appropriate by Sensei Ewan Hewett
- Any conduct, whether within or outside Yorkshire Martial Arts Ltd which may damage the reputation of Yorkshire Martial Arts Ltd, its Instructors or its Students will be deemed to be a disciplinary matter
- All decisions regarding disciplinary procedures are final.
Student/Parent/Guardian Declaration
I understand that in the event of any injury or illness to myself/child in my care, all reasonable steps will be taken to contact me and to deal with the injury or illness appropriately. Should I not be available I give consent for a qualified first aider to decide on appropriate care.

I confirm to the best of my knowledge that I do not/my child does not suffer from any medical condition other than those listed in the Physical Health section of this form. I consent to receiving/my child receiving medical treatment which, in the opinion of a qualified first aider, may be necessary.

I have read and understood the full contents of this Declaration/Membership Form and agree to be bound by its contents/I have explained the full contents of this membership form to the student and they agree to be bound by its contents.
Signature of Student/Parent/Guardian*

Clear
Date*

DayMonthYear
Date
How we use your data
Yorkshire Martial Arts Ltd will store your information electronically and it may be shared with third parties who have a legitimate use for it; such as our management company, franchisor and governing body. It will not be shared with third parties for purposes other than those necessary to effectively provide our services and to ensure the health and safety of our staff and customers. Yorkshire Martial Arts Ltd is registered with the Information Commissioners Office and will at all times handle your information in compliance with current data protection legislation.
Should be Empty: