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West London Insurance Application
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Student License and Insurance Application
Annual Insurance and License Fee valid until 18th December 2021. In order to adhere to national governing policies, Kenshukai Karate is required to renew their member to member insurance for all students, this is an annual fee of £22.
Student License and Insurance Application West London 2021
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Indicates required field
Select One
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Existing student
New student
Student name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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Date of Birth
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Class location attending/Dojo
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Medical History (Do you suffer from any of the following)
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None
Allergies
Asthma
Diabetes
Epilepsy
Haemophilia
Heart Disorder
Hay Fever
Nervous Disorder
Respiratory Disorder
Migraine
Joint/Skeletal
HIV
Other
Additional Details
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Criminal History (Have you ever been charged or convicted with any crime of violence?
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No
Yes
Please give details
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Photography and Video
In accordance with the Good Practice Guidelines for use of photography and video produced by NAKMAS National Governing Body, it is suggested that written consent be received from all parents or guardians when taking photographs or videos of children. Kenshukai Karate UK is committed to ensuring good practice is followed in relation to photography and video use within martial arts activities. This includes adherence to safe storage guidelines, as outlined in the NAKMAS Welfare Policy.
I consent to involvement in martial arts activities being photographed or recorded on occasion and for these images to be viewed and displayed.
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Within the premises e.g. notice boards
In promotional material e.g. a flyer
On websites
Any of the above
Data Protection
I understand that this form will be sent to Kenshukai Karate UK for my student license to be processed and my information used in accordance with Kenshukai Karate UK Privacy Policy. I CONSENT to being contacted via
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Email
Telephone
Text
Any of the above
Declaration
I declare that the following information is true and correct, and that I will abide by the policies and procedures as laid down by Kenshukai Karate. I accept that the practise of any martial art/combat sport involves the risk of serious injury.
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Agree
Parent/Guardian name if under 18
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Submit