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West London Pre-Training Questionnaire
Pre-Training Questionnaire-I
t is essential that this form is completed PRIOR to any martial arts training
*
Indicates required field
Student name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Date of Birth
*
Class location attending/Dojo
*
Family Doctor details
*
Details of any other Martial Arts experience or Sports Activities
*
Details of any particular goals or reasons for training
*
Medical History (Do you suffer from any of the following)
*
None
Allergies
Asthma
Diabetes
Epilepsy
Haemophilia
Heart Disorder
Hay Fever
Nervous Disorder
Respiratory Disorder
Migraine
Joint/Skeletal
HIV
Attention Deficit Hyperactivity Disorder (ADHD)
Dyspraxia/Co-ordination differences
Autism/Asperger's Syndrome
Sight/Hearing differences
Other
Additional Details
*
Declaration
I have completed this form to the best of my knowledge and I will inform you should any of these details alter at any time.
*
Agree
Parent/Guardian name if under 18
*
Submit