ANNUAL LICENCE APPLICATION
Association:
Instructor Name:
Surname:
First Names:
Address:
Post Code:
Home:
Date of Birth:
Work:
Occupation:
Male/Female:
Nationality:
Present Grade:
Who graded you?
Email address:
Date of Grading:
Have you, at any time had any of the following: please tick as appropriate
High blood pressure / stroke
Epilepsy
Diabetes
Hepatitis
Heart Problems / Angina / murmur
Arthritis
migraines
Bone/Joint injuries
Major operations
muscle injuries
Pregnancy
Asthma / Hay Fever
On medication now
Have you any other medical / physical problems which you think might interfere with your participation in this tr
aining programme which we should be aware of ? please give details in the space provided.
Do you have any past criminal record? Please give details on a separate sheet.
LICENSE FEE / MEMBERSHIP
Note: Both the FSKA and Karate England Membership/Insurance are Valid for ONE year only. Please renew by th
e expiry date on your registration slip.
Signature of Applicant:
Dated:
(Parent or Guardian to sign if applicant is under 16 years of age)
PTO
Please attach one photo
here and clip one more
to the top of this form.
ANNUAL LICENCE APPLICATION
DECLARATION
I promise to uphold the true spirit of KARATE-DO, follow the DOJO-KUN and never to use the skill
s I am taught against any persons, except for defence of myself, family or friends in the instance
of extreme danger or unprovoked attack, or in support of law and order.
I have no health risk / illness (other than stated overleaf) nor have I been advised by a doctor no
t to take physical exercise.
I understand that whilst taking every reasonable precaution the instructor can not be held respo
nsible for any injuries sustained and that the practice of Karate may involve risk of serious injury
during training.
Signature of Applicant:
Dated:
(Parent or Guardian to sign if applicant is under 16 years of age) :
For OFFICIAL use only
For OFFICIAL use only
KARATE ENGLAND
REGISTRATION No.
Issue Date:
Expiry Date:
Fee Paid:
KARATE ENGLAND
REGISTRATION No.
Issue Date:
Expiry Date:
Fee Paid:
For OFFICIAL use only
For OFFICIAL use only
KARATE ENGLAND
REGISTRATION No.
Issue Date:
Expiry Date:
Fee Paid:
KARATE ENGLAND
REGISTRATION No.
Issue Date:
Expiry Date:
Fee Paid:
For OFFICIAL use only
For OFFICIAL use only
KARATE ENGLAND
REGISTRATION No.
Issue Date:
Expiry Date:
Fee Paid:
KARATE ENGLAND
REGISTRATION No.
Issue Date:
Expiry Date:
Fee Paid: