Shihan Franks Karate Academy Karate Training and Body Development

APPLICATION AND MEMBERSHIP FORM

This form is copy and paste only; Copy and paste to a word document print, complete and return to the Dojo on training evening.

FEES: Membership = $20
Insurance one year = $15. Total joining fees $35 per person.

1. Applicants Details:

Last Name:………………………………………………………………………….

Given Names:……………………………………………………………………….

Address:…………………………………………………………………………….

Date of Birth:……………………………………………………………………….

Ph (Home):………………………………………………………………………….

Ph: (Mobile):……………………………………………………………………….

Ph: (Emergency Contact):…………………………………………….

2. Health Declaration:

Are you prescribed drugs which may impair reaction time or judgment?

NO

YES….Please give details………………………………………………………

Have you suffered any incapacity requiring medical attention in the past 12 months?

NO

YES….Please give details………………………………………………………

Name and identify any psychical impairments, injuries or medical conditions that currently affect you.

…………………………………………………………………………………….

Are you aware of any health problems that you have that, in the interests of your safety, the academy/club should be advised of?

NO

YES….Please give details……………………………………………………..

3. Martial Arts History

Have you studied Martial Arts before?

NO

YES….Please give details.

Style…………………..Grade…………………………………….

No of Years…………..Instructors Name……………………….

4. Exclusion of Applicant

Have you ever been excluded from Martial Arts in the past by a Medical Practitioner or any other person, entity or Martial Arts Club?

NO

YES….Please give details……………………………………………………..



I have read and understood the terms of the Martial Arts Contract or if I did not understand the terms of the contract, I requested an independent person to explain them to me. Applicants Signature………………………………………………………Date:…………………………………

Witness Signature………………………………………………………Date:…………………………………

6. Guardians Consent (for all persons under 18 years)

I hereby certify and decree that all the information contained in the declarations above is true and accurate.

Guardians Signature……………………………………………………...Date:…………………………………

Relationship to Applicant…………………………………………………

Address…………………………………………………………………….

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