ࡱ> oqnq` >bjbjqPqP  A::%   rrr8$t ]pNN$!J%%L&(\\\\\\\$_ha]] /'%"(%"/'/'] $!e]K*K*K*/'  $!\K*/'\K*K*2XDL vZB (Φ}r'jvY&ZL{]0]Y b( bLvZ b vZ B&"d&K*|&&B&B&B&]])jB&B&B&]/'/'/'/'   dr   r    JUNIOR MEMBERSHIP FORM Saint Martins junior karate club We are very pleased to welcome you to the Saint Martins Junior Karate Club. To ensure we have the correct contact details for you, please fill out this form and give it back to one of the instructors. If you are under 16 please also ask your parents or carer to sign the form before it is returned. We will also use this information to ensure that you are kept informed about club events. Personal details Name:  FORMTEXT      Address: FORMTEXT      Postcode: FORMTEXT      Home telephone number: FORMTEXT      Mobile: FORMTEXT      Email: FORMTEXT      Date of birth: FORMTEXT       Disability The Disability Discrimination Act 1995 defines a disabled person as anyone with a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. Do you consider yourself to have a disability? Yes  FORMCHECKBOX No  FORMCHECKBOX If yes, what is the nature of your disability?Visual impairment FORMCHECKBOX Hearing impairment  FORMCHECKBOX Physical disability FORMCHECKBOX Learning disability FORMCHECKBOX Multiple disability FORMCHECKBOX Other (please specify): FORMTEXT       Sporting information Have you done Karate before? Yes  FORMCHECKBOX No  FORMCHECKBOX If yes, where have you played the sport: (please indicate below)Primary school  FORMCHECKBOX Secondary school FORMCHECKBOX Local authority coaching session(s) FORMCHECKBOX Club FORMCHECKBOX County FORMCHECKBOX Other (please specify): FORMTEXT      Medical information Please detail below any important medical information that our coaches/junior coordinator should be aware of (eg epilepsy, asthma, diabetes etc.) Emergency contact details To be completed by the parent/carer Please insert the information below to indicate the person(s) who should contacted in event of an incident/accident. Contact name eg parent/carer: Emergency contact number: By returning this completed form, I agree to my son/daughter/child in my care taking part in the activities of the club. I understand that I will be kept informed of these activities for example timing and transport details. I will inform the club of any changes to the above details. I understand in the event of injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately. 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