The Newport Karate Centre

Title -- Title --MrMrsMissDrRev

Gender Gender Female Male

First Name

Surname

Age

Telephone

Email Address

Current Grade -- Current Grade --10th Kyu White Belt9th Kyu Red Belt8th Kyu Orange Belt7th Kyu Yellow Belt6th Kyu Green Belt5th Kyu Purple Belt4th Kyu Purple/White Stripe Belt3rd Kyu Brown Belt2nd Kyu Brown/White Stripe Belt1st Kyu Brown/2 White Stripes Belt1st Dan Black Belt2nd Dan Black Belt3rd Dan Black Belt4th Dan Black BeltDon't KnowDifferent Style

Why TheNKC -- Why TheNKC --want to learn Karatewant to keep Fitam looking for a New Clubwant to learn Self Defence

Please send me a club registration form Please send me a club registration form No Yes

Please send me a club registration form via the following Please send me a club registration form via the following By Email By Post

Message

Title -- Title --MrMrsMissDrRev

Gender Gender Female Male

First Name

Surname

Date of Birth dd-mm-yy

Telephone

Email Address

Do you have any Martial Arts experiance Do you have any Martial Arts experiance No Yes

Martial Arts Experiance -- Martial Arts Experiance --NoneKarateKung FuJiu-JitsuJudoAkidoOther

Please provide full details of any Martial Arts experiance you have

Fitness Level -- Fitness Level --very poor fitness levelpoor fitness levelgood fitness levelexcelent fitness level

Medical condition -- Medical condition --very poor conditionpoor conditiongood conditionexcelent condition

Do you suffer from or had any of these medical conditions: Do you suffer from or had any of these medical conditions: Asthma or Breathing Issues Epilepsy Heart or Kidney Issues Back, Knee or Joint Issues High Blood Pressure Blood Disorders Mental Illness Ongoing Medical Attention Other

Please provide full details of the medical condition

Please provide full details of any medical attention you are currently receiving

Has a medical expert assessed you unfit to practice Karate Has a medical expert assessed you unfit to practice Karate No Yes

Do you have any or are suffer from any physical limitations Do you have any or are suffer from any physical limitations No Yes

Please provide full details of any Physical Limitation

Do you take or are you currently on Prescribed Medications Do you take or are you currently on Prescribed Medications No Yes

Please provice details of any and all prescribed medications you are taking

Do you suffer from or have any allergies that you know of: Do you suffer from or have any allergies that you know of: No Yes Unknown

Please provide details of all allergies

Do you have any (pending) convictions for a Violent Crime Do you have any (pending) convictions for a Violent Crime No Yes

Please provide full details of any Violent Crime you committed

As a visitor to the 'Newport Karate Centre', I accept that training in the art of Karate involves a risk of serious injury and cauld cause serious injuty to myself and others. As a visitor to the 'Newport Karate Centre', I accept that training in the art of Karate involves a risk of serious injury and cauld cause serious injuty to myself and others. By ticking this box, I hereby indemnify the 'The Newport Karate Centre' it's clubs and all of it's instructors, members and or visitors to those clubs in respect of any accident or injury arising from instruction or class participation. I also accept that neither the 'The Newport karate Centre' or any of it's club instructors will bear responsability for any loss of property or money brought onto the clubs facilities.

Any other additional information about we need to know about

I confirm that all the above information at the time of completion was true and accurate and complete understand that by submitting this form does not garuntee that I will be accepted. I confirm that all the above information at the time of completion was true and accurate and complete understand that by submitting this form does not garuntee that I will be accepted. By ticking this box, I Confirm the above is TRUE & Accurate