Applicant’s Details

Student’s Name: Parent’s Name: Street Address: Address (continued): City: State: Zip / Postal Code: Home Phone:     Cell Phone:     Email: Date of Birth: Occupation:

Health Declaration

Are you prescribed drugs, which may impair reaction time or judgment? Yes     No If Yes, what drugs:   Have you suffered any incapacity requiring medical attention in the past 12 months? Yes     No If Yes, what drugs:   Name and identify any physical impairments, injuries or medical conditions that currently affect you:   Are you aware of any health problem/s that you have that, in the interests of your safety, the club should be advised of? Yes     No If Yes, what drugs:

Martial Arts History

Have you studied martial arts before? Yes     No If Yes, please state particulars:   Style:   Grade Achieved:   Number of years studied:

Exclusion of Applicant

Have you ever been excluded from Martial Arts in the past by a medical practitioner, or any other person, or entity, or a Martial Arts Club? Yes     No If Yes, what drugs:

Declaration of Understanding

Martial Arts Is Dangerous 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. Date: Signed: Applicant Signature:

Guardian’s 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. Relationship to Applicant: Signed: Guardian Signature: