International Aiki Budo Council

Kogusoku Aikido Association

1. Personal details: Please print clearly

First Name:

Surname:

Address:

Post Code:                                                                                           Tel No:

DOB:

Email Address:

2. Club Details:

Club Name:

Club Style:

Club Address:

Post Code:

Instructor:

Instructor’s Grade

3. Type of Licence Required:                                                                                         Tick One:

Junior Student (Under 16 years old)

Senior Student (16 years old & over)

Date Paid:

4. Medical Details:  If you have any of these conditions, tick boxes. Give details overleaf                                                                            

Epilepsy

Diabetes

Heart Disorder

Haemophilia

Contagious

Disease

Visual Disorder

Hearing Disorder

Respiratory Disorder

Eg Asthma

5. Background:

Have you ever been convicted of a crime of violence?  Yes / No. If yes please give details.

6. Declaration:

I confirm that all details given are correct:

I accept that the practice of martial arts/combat sports involves the risk of injury.                   Please Delete One

I give my permission for my child to be taken to hospital in the unlikely event of an accident.            YES / NO

Signature                                           Date                    Signature of Parent/Guardian in under 16 years old

 Membership Fee:             

 Adults    £20.00 = 01 May – 31 July / £15 = 01 Aug – 31 Oct / £10 = 01 Nov – 31 Jan / £5 = 01 Feb – 30 April

 Juniors and Full Time Students £10.00 = 01May – 31 July / £7.50 = 01 Aug – 31 Oct / £5 = 01 Nov – 31 Jan / £2.50 = 01 Feb – 30 April