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First name

Last name

Date of Birth

Day

Month

Year

Phone

Please include country code (e.g. +44)

Email

Address

Other

Current Grade (if applicable)

Date of Last Grading (if applicable)

Old Licence Expiry (if applicable)

Have you ever been convicted of a crime of violence?

Yes

No

I acknowledge that the practice of any martial art involves the risk of injury. I accept the responsibility of informing the instructor before the session of any injuries or circumstances that may affect my eligibility for training. I the undersigned confirm that all of the information provided above is accurate. I understand that any false information provided will invalidate my membership and may lead to expulsion from the association.

I agree to abide by the Dragons Karate code to not use my art except in the defence of myself, family/friends and law and order. I also acknowledge that you reserve the right to decline any application.

Data Protection Act

Dragons Karate currently holds information you entered on the membership application form. These details will only be stored for the purpose of applying & renewing your licence. Your details will only be provided to the insurance broker and company that arranges your cover. Dragons Karate will not sell or pass on this information to any other body. Your details will be held for a period of 7 years in line with legal and insurance requirements.

Date

Day

Month

Year

Signature

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