West London Insurance Application

Annual Insurance and Licence Fee valid until 18th December 2022 (4 months free-remainder of 2021 included). 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 2021-22

* Indicates required field

Select One *

Student name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Date of Birth *

Class location attending/Dojo *

Medical History (Do you suffer from any of the following) *

Additional Details *

Criminal History (Have you ever been charged or convicted with any crime of violence? *

Please give details *

Photography and Video

In accordance with the Good Practice Guidelines for use of photography and video, 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 our 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. *

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 *

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. *

Parent/Guardian name if under 18 *

Submit