Personal details

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Any existing medical conditions?

Diabetes

Epilepsy

Haemophilia

Heart disorder

Migraine

High blood pressure

Respiratory problems (Asthma)

Other

Photographs and videos may be taken during lessons and used in club promotional material and/or club social media sites. I consent to pictures being used *

Yes

No

I consent to this personal data being held by ECKA Bletchley Dragons Karate Club. *

I understand that I practice Karate and associated activities at my own risk. I shall not hold responsible the ECKA, its principal officials, instructors or fellow members for any injury I may sustain. I understand membership is non-transferable and that all monies paid are non-returnable.

Yes