Join Us Malvern Shotokan Karate Club Membership Form Contact Information: Name of Member Parent/Guardian Name (If member under the age of 18) Address Email Phone No Mobile No Date of Birth (Member) Contact details in case of emergency: Emergency Contact Name: Emergency Contact Mobile No. Medical Information Do you consider yourself to suffer from any form of disability? YesNo If yes, please specify: Any such illness contracted at anytime must be brought to the attention of the instructor immediately. Any information given will be treated in the strictest confidence. Photography / Publicity: Malvern Shotokan Karate Club may take official images of training sessions, competitions, gradings etc. The club will hold images recorded and my be used in external publication, website, or in the press to show what the club does. I confirm the club may use images of myself or my child (children) in any publication: YesNo Please read the Following: To the best of my knowledge, myanswers to the questions are accurate and true. I promise to abide to the rules and regulations of the club and observe the dojo and karate codes. I recognise and acknowledge that the instruction which I am given is in good faith, and that the purpose and intention is to improve my karate skills, knowledge and fitness for the participation of Shotokan karate. I recognise and acknowledge that the kumite (fighting) aspect can result in physical contact and possible injury, and that although every effort is made to avoid the occurrence of injury, accidents might happen. I understand and agree that the instructor cannot be held responsible should I incur or suffer and injury during training, courses or competitions. Digital Signature: By entering your full name below, you are digitally signing and acknowledging to agree to the statements above, and are confirming the above entered details are correct (Parent/Guardian name to be used if member under the age of 18): Please tick the below and then Send: By using this form you agree with the storage and handling of your data by this website.