International ShinKen-Do Organisation
Student Annual Membership/Insurance and Application Form

Tel: 0207 790 2522 Email: info@ShinKen-Do.com www.ShinKen-Do.com

 

Full Name (Capitals) ___________________________________________________________________________________________________

Address (Capitals) ____________________________________________________________________________________________________

____________________________________________________________________________________Post Code_______________________

Date of Birth______/_______/_______ Occupation____________________________________________Tel Home_______________________

Mobile______________________________________________________Email____________________________________________________

Pre Exercise Medical Questionaire:
Please answer Yes or No to the Following Questions

Have your Doctor ever said you have heart disease or any other cardiovascular problem? YES/NO
Is there a history of heart disease in your family? YES/NO
Has your doctor ever said you have high blood pressure? YES/NO
Do you ever have pains in your heart and chest after undergoing minimal exertion? YES/NO
Do you often get headaches feel faint or dizzy? YES/NO
Do you suffer from pain or limited movement in any joints or bones which have
ever been aggravated by exercise or might be worse by it? YES/NO
Are you taking drugs medication or recuperating from a recent illness or operation at the moment? YES/NO
Do you have any other condition that might affect your ability to practice ShinKen-Do alleged activities? YES/NO
Are you 35 or over and unaccustomed to physical exercise? YES/NO

If you have answered YES to one or more of the above questions consult your doctor and a medical note
of approval is required before starting your training.
If you have answered NO to all of the above questions you should feel assured that you are ready to begin.

When last did you have a medical? _______________________________________________________
Personal:
Have you ever been convicted of a crime? YES/NO
If YES may we ask to provide and or enquire or taking a police check to the nature of the crime? YES/NO
(The International ShinKen-Do Organisation reserves the right to refuse an applicant)

Have you practised Martial Arts before? YES/NO
If Yes please give details including duration and grade obtained___________________________________________
______________________________________________________________________________________________
Are you the person named on this form? YES/NO

Note:
Annual Insurance/Membership. Senior (16 years and over £60 includes uniform) Junior (14 and 15 £40 includes uniform)
Please provide two passport size photos to accompany this form. All checks should be made payable to the British ShinKen-Do Organisation.
DECLARATION

I ___________________________________have read, answered and fully understood all the questions and wish to apply for membership of the International ShinKen-Do Organisation. I hereby agree to abide by the constitution and the by-laws of the International ShinKen-Do Organisation. I am fully aware that the practice of ShinKen-Do alleged activities is entirely at my own risk. I shall not hold responsible the Club, other club members, its principle officers, or instructors for any injury that I may sustain. I understand that membership is non transferable and that all monies paid are non refundable.

Signed ______________________________________________________ Date _____/____/____

Signature of Parent or Guardian
for applicants under 16 years old ___________________________________Date _____/____/____

The International ShinKen-Do Organistion are registered and insured members of the British National Martial Arts Association