Consultation Form

This form is to be filled by new students who wish to train with Galway Shotokan Karate Club. This is not a membership form.All the information provided in this form will be used solely for the purpose of club training and will not be shared with other parties.

Student details

First Name*

Last Name*

Address*

Email*

Date of Birth*

Home Phone Number

Mobile Number*

Occupation

Date of joining the club

Age category*

7 to 13 years

14 to 17 years

18 years and above

Any previous martial arts training?*

I have trained before

I am a complete beginner

Please give training details*

Contact details in case of emergency

Name*

Emergency name

Daytime phone number

Mobile number*

Doctor's name*

Doctor's number*

Parental / Guardian Consent

This parental consent covers the regular training, grading and competing within the Irish United Karate-Do Kai. This also covers any exceptional travel or residential trips. This must be completed for all students under the age of 18.

In the event of illness or accident, I give permission for medical treatment to be administered where considered necessary by a suitably qualified medical practitioner and/or hospital.

I understand that every effort will be made to contact me as soon as possible. In an emergency, I can be contacted at the numbers given below.

I agree to allow the child named above to take part in Galway Shotokan Karate Club training, grading and competition. I understand that there will be suitable supervision while the young people are in the care of the IUKK.

I understand that the proceeding may be photographed / videoed and used for promotional purposes.

I am giving consent to the above

Name of parent/guardian 1*

Relationship to child/young person*

Daytime phone number*

Home phone number

Mobile number*

Signature parent/guardian 1*

Name of parent/guardian 2

Relationship to child/young person

Daytime phone number

Home phone number

Mobile number

Signature parent/guardian 2

Student declaration

I declare that the information I have given is correct and that as far as I am aware I can undertake training without any adverse effects. I do not suffer any contagious diseases (diarrhoea, vomiting etc) which could spread to other students in the Dojo and I am not under the influence or recreational drugs or alcohol.

I acknowledge and understand that Shotokan Karate (and all associated training exercise) is a physical contact sport and carries with it potential for injury. I hereby agree to voluntary assume the risks of participating in Karate (and all associated training exercise) in consideration of becoming a member.

I hereby declare that I am medically able to properly train and assume full and complete responsibility for any injury or accident that may occur while I am training in Karate or competing in tournaments.

I am aware and assume all risks associated with training in Karate, including but not limited to falls, contact with other students, and condition of the premises being used. I for myself and my heirs and executors hereby waive, release and forever discharge the instructor of Irish Karate, sponsors, promoters and each of their agents, representatives of all my liabilities, claims actions or damages that I may have against them arising out of or in any way connected with my participation in Karate.

I confirm that I have read and agreed with the declarations above.

Signature of student*

Signature of parent*

Date

Student details

Contact details in case of emergency

Medical details

Parental / Guardian Consent

Student declaration