SPEYSIDE SCHOOL OF TAEKWON-DO APPLICATION FORM

Name
Telephone (inc. STD code):
Mobile:
Address:
Postcode:
E-mail:
Weight (kg):
Height (cm):
Date of Birth:
Employer:
Occupation:
Nationality:

Include with application:

Membership (aged 13 & over) OR	£32.00
Membership (aged 12 & under)	£22.00
Practice suit (up-to age 8 approx.) OR	£30.00
Practice suit (junior & adult)	£35.00
Total included		£

Plus: Three passport photographs

Completed 'Confidential Medical History'

Confidential Medical History

1 Have you ever suffered from any of the following?

Asthma	Yes / No
Diabetes	Yes / No
Epilepsy	Yes / No
Heart complaints	Yes / No
Allergies	Yes / No
Please specify:
Head injuries	Yes / No
If yes: How long ago? Were you unconscious? For how long?	Yes / No
Any other major illness or previous injuries which may affect participation?	Yes / No
Please specify:

 2 If you have answered yes to any question:

Is the condition under medical control?

Yes / No

3.

Do you need to have any medication withyou during activity?	Yes / No
If the answer is yes, how is the form of medication taken?

4 Have you had the following inoculations:

		Date
Tetanus	Yes / No
Polio	Yes / No
BCG	Yes / No
Hepatitis	Yes / No
Smallpox	Yes / No

Signed: __________________________________

Print name: _____________________________________________ Date: ___________________

If under 18 years of age, parent / guardian must sign below:

Signed: _____________________

Print name: ___________________________ Date: ________

Relationship: Parent / Guardian - please circle

All future changes to your medical fitness must be communicated to your Instructor.

Those with current medical conditions or injuries must consult their Doctor prior to the start of their training.

PLEASE RETURN TO: S CATTANACH, 75 HIGH STREET, ABERLOUR, SPEYSIDE, AB38 9QB