London Karate dō Shōtō Association Membership Application Form

London Karate dō Shōtō Association Membership Application Form Please write in block capitals and in black ink ALL sections must be filled in incomplete forms will be rejected BASIC INFORMATION Last name: First name(s): What name is the applicant normally addressed by? Please tape a current passportsized photo here (Remember to put your name and date of birth on the back) Gender: Male/Female* Date of Birth: Home address: Work/School address: Mobile No. Email: Occupation: Height (cm): ADDITIONAL INFORMATION Next of kin: (for applicants under 18 years of age, this must be the legal guardian) Family Doctor: Last name: Relationship to Applicant: Home Address: Name: Address: First name(s): Home Work Mobile No. Email: Fax No. E mail: * Delete as appropriate

HEALTH HISTORY (ALL Sections Must Be Completed) Has the applicant ever suffered from any of the following conditions? (Tick relevant boxes): Asthma... Epilepsy and/or fits... Hearing differences... Respiratory disorder... Migraine... Visual defect(s)... Hay fever... Dyslexia... Liver disorder... Allergies... Dyspraxia... Hepatitis... Heart disorder... Coordination differences... HIV/AIDS... Blood pressure disorder... ADHD... Diabetes... Haemophilia... Autism/Asperger s Syndrome... Kidney disorder... Blood disorder... Mental health disorder... Back/Joint condition... Other (please give full details): If any of the above boxes have been ticked, please also give full details: Tetanus Vaccinations (necessary in case of outdoor training events etc.) Infant set of 3 doses given Booster dose received... Date of last booster dose: MARTIAL ARTS HISTORY Is the applicant currently practising another martial art?... Yes/No (delete as appropriate) If yes, please give details (name of martial art and duration of practice): Has the applicant ever practised another martial art?... Yes/No (delete as appropriate) If yes, please give details (name of martial art, association/club name, training period, grade achieved): Declaration I declare that the above information is true and complete to the best of my knowledge, and that I will abide by the policies and procedures as laid down by the London Karate dō Shōtō Association. If any of the above information changes, I shall inform the coach (in writing) prior to continuing the applicant s training in the club. I understand that failure to disclose or, indeed, failure to accurately represent information may result in rejection of the applicant s membership of the karate club. I also understand & accept that the chief instructor has the final decision in the approval/rejection of membership or suitability of any applicant to practice the art at any stage of the applicant s training. If the applicant is under the age of 18 years, this form MUST be signed by the legal guardian of the applicant. Otherwise the application cannot be accepted. Print FULL name of applicant: Date of Birth of Applicant: Print FULL name of legal guardian: (if applicant is under 18 years of age) Signature of applicant: Date of (or legal guardian if applicant is under 18 years of age) Signature:

TERMS AND CONDITIONS OF MEMBERSHIP I hereby accept the following conditions of my membership of the London Karate dō Shōtō Association (LKDSA): 1. Club Authority 1.1. In all points raised below & all matters pertaining to the LKDSA, I accept that the Deputy Chief Instructor will carry the full authority of the Chief Instructor in his/her absence. 1.2. The grades of proficiency that I may be awarded from time to time are a privilege, not a right, granted at the discretion of the instructors and examiners. The Chief Instructor of LKDSA, as the highest technical authority in the club, may therefore alter my grade/rank at any time (up or down) without prior notice at his/her sole discretion. 2. Behaviour & Discipline 2.1. I promise not to use knowledge/skills that I am taught except in defence of life, honour or truth and, even then, as a last resort when all other options have been exhausted. 2.2. I promise never to do anything that may bring shame, disrespect or dishonour to my teacher, my club or myself. 2.3. I promise not to damage any equipment or item belonging to the LKDSA. 2.4. I accept that no photographic, videographic or media material may be obtained in the club or during club events without the prior permission of the chief instructor. 2.5. I accept that in all matters pertaining to my training and discipline, the Chief Instructor s decision is final and cannot be appealed. 3. Finance issues 3.1. I accept that class fees are payable by the following methods: 3.1.1. Paid monthly by standing order (s/o) mandate. This is due at the end of each month, prospectively, for the forthcoming month, eg. Fees for June are due by 31 May. I understand these payments are to continue monthly for ALL TWELVE calendar months because the cost of 10 months training (the academic calendar) is spread evenly over 12 months to make it less of a financial burden. Therefore, even though students are not charged for school holiday periods (Christmas, New Year, Easter, summer holidays etc.), payments that are made during these periods are effectively paying back some of the cost of the remaining ten months of training. 3.1.2. Paid per semester (4 calendar months at s/o rates), which is due in cash or cheque PRIOR to the commencement of the semester. 3.1.3. Paid per lesson at a flat rate, which is due in cash PRIOR to the commencement of the lesson. The fee for each lesson is calculated thus: highest monthly s/o rate (for adults or children respectively) divided by 5 (except for the introductory lessons which are divided by 10). 3.2. I understand that the latest fee rates can be obtained from the Club Treasurer or Chief Instructor. 3.3. I acknowledge that any alternative payment structure must be accepted in writing either by the Chief Instructor, Deputy Chief Instructor or Club Treasurer. 3.4. I promise to pay any fees due by me to the club on time and without delay. I recognise that if payment is late without a reason, submitted in writing, that is acceptable to the Chief Instructor or Chairperson, I am liable to incur a 1% penalty (compounded daily) on any outstanding fees or dues. If this delay persists beyond a month, either my membership may be terminated or the rate of penalty will rise to 2% daily from the 31 st day of delay onwards. 3.5. I acknowledge that all arrears are due within 5 working days from the date of any written notification by the club to the student (or student s guardian). I accept that if arrears are not paid within the 5 working days, my membership will be immediately suspended and that, if I still cannot clear the arrears within 2 weeks from the date of the written notification by the club, my membership will be terminated. I understand that if I should wish to resume training after this point, I will have to apply as a new student (i.e. licence/insurance/membership fee will be due etc.). 3.6. I understand that all payments are non refundable. Furthermore, I understand that if a cheque is dishonoured by the bank then I will be liable to pay LKDSA a 20 handling fee. 4. Liability 4.1. I accept that the practise of any martial art/combat sport may involve the risk of serious injury. 4.2. I accept that it is my responsibility to ensure that my licence and insurance are up to date at the time of any practice that I take part in. 4.3. I accept that it is my responsibility to look after my personal belongings during practice sessions. 4.4. I acknowledge that LKDSA does not accept any responsibility or liability for any theft, loss or damage of any of my personal belongings. 4.5. I further acknowledge that, if I should steal, lose or damage any equipment or item(s) belonging to the LKDSA, I am responsible for the cost of replacing such item(s). 5. Licence/Membership Status 5.1. If I am granted a licence to practice, I accept that this is always the property of LKDSA which may be given to me for safekeeping. I will willingly surrender it immediately upon request by the Chief Instructor at all times. 5.2. I promise to inform London Karate dō Shōtō Association (in writing within 5 working days) if any of my details held in this document should change. 5.3. I accept that the terms and conditions of membership as well as any fee structure may, from time to time, change according to the changing needs of the club. I understand that, if this should happen, I will be given prior written notice of these changes. 5.4. I may request withdrawal of my membership of the London Karate dō Shōtō Association by giving one month s notice to the Chief Instructor or Chairperson, in writing. This one month may be used by the Club Management Team to resolve any outstanding administrative matters. 5.5. I accept that if any of the points in these terms and conditions are violated by me, my membership of the London Karate dō Shōtō Association may be suspended or terminated immediately without notice, at the sole discretion of the Chief Instructor or Deputy Chief Instructor. 6. Renewal of Membership 6.1. I recognise that my membership, if accepted, is only valid for one year from the date of my signature below in the first instance, subject to a review at the end of the year. After the yearly review, if successful, they may be offered membership for a further year. During this annual period, I understand and accept that the following (amongst other things) will be assessed: Enthusiasm and motivation for the Art. Level of dedication and commitment to learning. Ability to integrate into the club, both as an individual and in terms of club policies. Particularly for children (though, to an extent, also for adult students), the ability to show good behaviour and appropriate respect towards their teachers and senior classmates. 6.2. I understand that only once a student reaches black belt standard will their annual membership application be considered for long term status. 6.3. I understand that I may be required to complete this application form again at the start of each new academic year or if the terms and conditions should change. 7. Management & Technical Executive 7.1. For all instructors/assistant instructors only, the following also apply: 7.1.1. I recognise that being a teacher is a high honour beyond measure & promise to carry the responsibility with humility, dedication and diligence. 7.1.2. I promise that any information given to me regarding students or martial arts will be held in confidence by me, never to be divulged expect with the sole permission of the Chief Instructor. 7.1.3. I promise to uphold myself in an honourable and dignified manner, setting a shining example to all those around me (in particular my junior colleagues) of the highest virtues of Bushido. I further promise to adhere to teaching the principles & guidance laid out by the Chief Instructor. 7.1.4. I acknowledge that I am directly answerable to the Chief Instructor alone or, in his/her absence, to the Deputy Chief Instructor for all of my actions in and outside the club both as a practitioner and a teacher. 7.2. For all members of the management team only, the following also apply: 7.2.1. I recognise that, as a member of the management team, I may be privy to information not otherwise disseminated. As such, I promise to carry out my role in the management team with honour and dedication and never to use the information I am given except for the purposes of club administration as directed by the Chairperson or Chief Instructor. 7.2.2. I will follow the direction and lead of the Chairperson and Chief Instructor and, if any conflict or dispute should arise, I will defer to the final decision of the Chief Instructor as the highest technical authority and most experienced practitioner in the club. My acceptance of the conditions laid down in this document is given freely and willingly, without any undue pressure. Print FULL name of Applicant: Print FULL name of Legal Guardian: (if Applicant is under 18 years of age) Signature of Applicant: (or Legal Guardian if Applicant is under 18 years of age) Date of Birth of Applicant: Date of Signature: OFFICE USE ONLY: Date applic n received: Application fee received: Amount: Date NAKMAS Number: Licence Expiry Date: Signed: Membership Status: Active/Provisional/Suspended/Terminated

NAKMAS NATIONAL GOVERNING BODY STUDENT LICENCE/INSURANCE APPLICATION PLEASE COMPLETE THIS FORM FULLY IN BLOCK CAPITALS Application for: Junior Licence [ ] Senior Licence [ ] Full Name:... Date of Birth:.. Address:.. Post Code: Telephone Number: (..) Occupation:. Martial Arts History: ( Have you ever practised a martial art? If so, please list details including grade achieved, date grade achieved and association/instructor). Medical History: (Do you suffer from any of the following? Please tick in the box provided) Allergy (ies) [ ] Asthma [ ] Diabetes [ ] Epilepsy [ ] Haemophillia [ ] Heart Disorder [ ] Hay Fever [ ] Nervous Disorder [ ] Respiratory Disorder [ ] Migraine [ ] Joint/Skeletal [ ] HIV [ ] Other [ ] Please give details:. Criminal History : Have you ever been charged or convicted with any crime of violence? Yes [ ] Details:..No [ ] DECLARATION I declare that the above information is true and correct, and that I will abide by the policies and procedures as laid down by the NAKMAS National Governing Body. I accept that the practise of any martial art/combat sport involves the risk of serious injury. I enclose with this application: 1. One passport type photograph (if hardback book is required) 2. Required application fee Signed:.. Signed:.. (students 18 years plus) (Parent/Guardian of students under 18 years) Date: NAK011 May 2001 PLEASE HAND THIS FORM TO YOUR INSTRUCTOR/CLUB SECRETARY, SO THAT IT MAY BE COUNTERSIGNED Club Registration Code: Chief Instructor/Club Secretary Signature:...

London Karate dō Shōtō Association Standing Order Mandate Please write in block capitals and in black ink TO THE MANAGER OF THE FOLLOWING BANK/BUILDING SOCIETY: Please set up the following standing order mandate & debit my/our (delete as appropriate) account accordingly ACCOUNT DETAILS Account Name: Account Holding Branch: Account Number: Sort Code: PAYEE DETAILS Account Name: London Karate dō Shōtō Association (LKDSA) Account Holding Branch: Paddington Branch Account Number: 01965923 Sort Code: 30 96 40 Please debit the amount of on the 24 th day of each month until further notice and commencing on the following date:. Yours sincerely, Name of Customer: Signature of Customer: Date of Signature: