Registration Form

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Occupation

Email

BRIEF MEDICAL QUESTIONNAIRE (CONFIDENTIAL)

Do you have any heart conditions, has a Doctor ever stated you should you should only do recommended exercises?
NoYes

Have you ever had a serious illness?
NoYes

Have you ever suffered a serious injury?
NoYes

Do you have any pain in your chest when doing exercise?
NoYes

Do you have any bone or joint problems?
NoYes

Are you taking any prescribed drugs?
NoYes

Do you suffer from Asthma?
NoYes

Do you use inhaler’s?
NoYes

Do you suffer from hemophilia?
NoYes

If you have answered Yes to any of the above please consult with you instructor and they may refer you to your doctor. You are obliged to inform your instructor should there be any changes to this at any time

Have you ever been found guilty by a court for any crime involving violence?
NoYes

Do you have any previous experience of martial Arts?
NoYes

Do you agree to abide with club rules presently in force and subsequent modifications/additions that from time to time are deemed necessary?
NoYes

Please indicate with a tick which aspect of Kickboxing/Fitness appeals to you most?
[eelect aspect "Keep Fit" "Self Defence" "Sparring" "Competition"]

How did you find out ABOUT our club ?

I the trainee indemnify the above club in respect of any injury caused to another member or against losses caused to the club by any act of mine or default.

I the trainee understand that the training and practice of the martial arts can be dangerous and agree to personally bear all losses caused by injury whilst engaged in it.

I the trainee understand to use my new skills responsibly and within the boundaries of the law.

I allow my image to be captured and used on our Facebook site and social media.

Payments are by direct debit and once you have signed you/your child up, you will be contacted via Gocardless for payment by email.