You are on page 1of 2

FULL NAME: ______________________________ AGE: _______________ SEX: ________________

DATE OF BIRTH: / / NATIONALITY: _____________________________

ADDRESS: ___________________________________________________________________________

CITY: ___________________________________ TEL: ______________________________________

EMAIL: __________________________________ MOBIL NUMBER: ___________________________

OCCUPATION: ____________________________ WORK NUMBER: ___________________________

PREVIOUS TRAINING EXPERIENCE: ______________________________________________________

DEGREE RECEIVED: ___________________________________________________________________

PLEASE STATE ANY HEALTH PROBLEMS YOU MAY HAVE (ASTHMA /DIABITIES etc)

DATE: ________________

WHICH STYLE WOULD YOU MOST LIKE TO PRACTICE?

HOW DID YOU HEAR ABOUT OUR CLUB?


FRIENDS
GOLDENPAGES
LEAFLETS
IRISHFIGHTER MAGAZINE
SHOP AROUND PAPER
OTHERS

I understand that the temple's instructors or other students are not responsible for accidents,
injuries or loss of property while training.

PLEASE PRINT NAME: ________________________________________

Signed: _____________________________________________________

IF UNDER 18 YEARS OLD


I do voluntarily agree to accept the responsibility and will not hold the club responsible for injuries
received by my son/daughter while training at the master's temple. I also understand that martial arts
are a sport that requires a great deal of exertion both mental and physical.
Student: _________________________________ Parent:____________________________________

Emergency Contact No:- _____________ Club Membership Card No: _________________

You might also like