Application Form

Applicant Details

First name

Last name

Address

Post Code

Would You Like To Join The Club Whatsapp Group?

Yes

No

Emergency Contact Details

Name Of Contact

Relationship To Applicant

Email

Phone

Medical Details

Does the applicant suffer from any medical condition which may affect their ability to train?

Yes

No

Does the applicant have any additional needs which we should be aware of?

Yes

No

Is the applicant currently seeing a doctor for any medical conditions?

Yes

No

If YES to any of the above please give details below:

Medication

Does the applicant currently take any prescribed medicines on a regular basis?

Yes

No

If YES to the above please give details below:

Please note it is the responsibility of the member or parent/guardian as applicable to inform Kesien Judo Club of any future medical/additional needs that affect the members ability to train or that we should be aware of.

Media

Photographs and videos may be taken by a person authorised by Keisen Judo Club. these photographs may be used in promotional literature, on the website/social media and for announcements of events concerning the club or press.

Do you give consent for photographs / videos to be taken of my child by Kesien Judo Club?

Yes

No

Do you give consent for photographs / videos to be used for promotional and publicity purposes?

Yes

No

Judo is a contact sport and carries certain risks, Keisen Judo Club cannot be held responsible for any injures arising from the participation in judo at its dojo or events.

Signature

Signature field is empty.

Parent/Guardian Name

Date

Day

Month

Year