Full Name
Date of Birth
Address Line 1
Address Line 2
Town
Post Code
Home Telephone
Mobile Telephone
Your Email
Occupation
Please declare any prior abuse convictions. Have you been the subject of any investigation or enquiry into abuse or other inappropriate behaviour? If yes, please provide details below.
Have you ever been convicted of a crime of violence? If Yes, please give details below.
1. Have you ever suffered from heart trouble? yesno
2. Are you taking any form of medication? yesno
3. Do you suffer from chest pain? yesno
4. Do you suffer from dizzy spells? yesno
5. Have you ever had either high or low blood pressure, and or high cholesterol level? yesno
6. Have you ever had asthma, chronic bronchitis or any other chest ailments? yesno
7. Do you suffer from severe back pains or an orthopaedic problem? yesno
8. Do you suffer from severe headaches or migraines? yesno
9. Are you recuperating from a recent illness/operation or injury? yesno
10. Have you any medical condition that we should be aware of? yesno
11. Are you pregnant? If yes how many months? yesno
12. Is there any history of heart disease in your immediate family (before age 55)? yesno
* If you have answered "Yes" to any of the 12 questions above, please provide additional information below:
If you answered yes to questions 1 to 12 you must seek medical advice/approval before commencing an exercise induction or programme including Karate.
I have been informed verbally and in writing that if I answer yes to any of questions 1 to 12 of these medical questions I must seek medical advice/approval before commencing this Karate exercise programme at Robin Park. If I wish to continue without such advice I do so at my own risk.
I confirm that I have read and fully understand and answered the above questions honestly. I understand that the instructors cannot be held responsible for any injuries or ill health of any kind arising form participation in the Karate sessions.
I accept that the practice of karate involves physical contact and that there is a risk of injury.
Personal data will be used in accordance with the club Privacy Policy which can be viewed on our website and a copy is available to view in the club.
I confirm I have read the notes and declaration and have answered all questions accurately
Today's Date
