TAEKWONDO

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EAST LONDON SCHOOL OF TAE KWON-DO
STUDENT LICENCE APPLICATION

PLEASE USE BLOCK CAPITALS AND COMPLETE EVERY FIELD

Surname *

First Names *

Mr/Mrs/Miss *

DOB*

Age *

House No. & Street *

Post Town *

County

Postcode *

Telephone *

E-mail *

Licence No

Expiry Date

Note: Please leave Licence number blank if you don't have it.

New

Renewal

Late Renewal

(tick one) *

DO YOU SUFFER FROM ANY OF THE FOLLOWING? (Tick if yes)

Heart Disorders

Asthma

Migraine

Haemophilia

Dyslexia

Hay Fever

Diabetes

Epilepsy

Nervous Disorders

Other Disabilities/Injuries:

(If necessary, continue on the back of this form)

HAVE YOU EVER BEEN CONVICTED OF A CRIME OF VIOLENCE? *

Yes

(If yes, an explanatory letter must accompany this form)

HAVE YOU EVER BEEN REFUSED MEMBERSHIP OF ANY MARTIAL ARTS SCHOOL/ASSOCIATION? * (If yes, an explanatory letter must accompany this form)

Yes

PHOTOGRAPHY DISCLAIMER: I understand that ELTKD may at times make use of photographic images of members for the promotion and/or teaching of Tae Kwon-Do.

I agree to abide by the rules and regulations of the ELTKD and understand that Martial Arts practice can carry a risk of injury.

Members Signature *

Date

Please generate your signature before you submit your application.

NB. Membership is inclusive of student to student liability insurance which is obligatory by law.

IMPORTANT: This form must be completed prior to commencing training. LICENCE APPLICATION/RENEWAL

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Gladesmore Sport Centre , Crowland Road, London N15 6EB

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EAST LONDON SCHOOL OF TAE KWON-DO STUDENT LICENCE APPLICATION

Sign Up for Your regular updates on our cubs

EAST LONDON SCHOOL OF TAE KWON-DO
STUDENT LICENCE APPLICATION