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Consultation Form
This consultation form is to be filled by new students who wish to train with Galway Shotokan Karate Club. This is not a membership form.
All the information provided in this form will be used solely for the purpose of club training and will not be shared with other parties.
Student details
Name
Surname
Address
Email
Home Phone Number
Mobile Number
Date of Birth
Occupation
Date of joining the club
Age category
18 years and above
Under 18 years
Facebook
Yes
No
Any previous martial arts training?
I have trained before
I am a complete beginner
Contact details in case of emergency
Name
Phone Number
Mobile Number
Doctors Name
Doctors Number
Medical details
1. Are you currently taking any medication?
Yes
No
Please give details
2. Are you allergic to any medication?
Yes
No
Please give details
3. Do you suffer from asthma?
Yes
No
Please give details
4. Do you have any allergies? (e.g. nets, bee stings etc)
Yes
No
Please give details
5. Do you have any recent injury?
Yes
No
Please give details
6. Have you been knocked out during the past 12 months?
Yes
No
Please give details
7. Have you had a head injury during the past 12 months?
Yes
No
Please give details
8. Do you have any ongoing medical conditions?
Yes
No
Please give details
9. Have you ever been to hospital?
Yes
No
Please give details
10. Please mention any other relevant information or medical conditions not listed above eg special needs, dietary requirements etc.
Parental / Guardian Consent
This parental consent covers the regular training, grading and competing within the Irish United Karate-Do Kai. This also covers any exceptional travel or residential trips. This must be completed for all students under the age of 18
In the event of illness or accident, I give permission for medical treatment to be administered where considered necessary by a suitably qualified medical practitioner and/or hospital.
I understand that every effort will be made to contact me as soon as possible. In an emergency, I can be contacted at the numbers given below.
I agree to allow the child named above to take part in Galway Shotokan Karate Club training, grading and competition. I understand that there will be suitable supervision while the young people are in the care of the IUKK.
I understand that the proceeding may be photographed / videoed and used for promotional purposes.
I am giving consent to the above
Name of parent / guardian 1
Daytime phone number
Home phone number
Mobile Number
Email
Relationship to child/ young person
Signature
Name of parent / guardian 2
Daytime phone number
Home phone number
Mobile Number
Email
Relationship to child/ young person
Signature
Student declaration
I declare that the information I have given is correct and that as far as I am aware I can undertake training without any adverse effects. I do not suffer any contagious diseases (diarrhoea, vomiting etc) which could spread to other students in the Dojo and I am not under the influence or recreational drugs or alcohol.
I acknowledge and understand that Shotokan Karate (and all associated training exercise) is a physical contact sport and carries with it potential for injury. I hereby agree to voluntary assume the risks of participating in Karate (and all associated training exercise) in consideration of becoming a member.
I hereby declare that I am medically able to properly train and assume full and complete responsibility for any injury or accident that may occur while I am training in Karate or competing in tournaments.
I am aware and assume all risks associated with training in Karate, including but not limited to falls, contact with other students, and condition of the premises being used. I for myself and my heirs and executors hereby waive, release and forever discharge the instructor of Irish Karate, sponsors, promoters and each of their agents, representatives of all my liabilities, claims actions or damages that I may have against them arising out of or in any way connected with my participation in Karate.
Student Declaration
I confirm that I have read and agreed with the declarations above.
Signature of student
*Signature of parent
Submit
Thank you for sending the form.
To discuss when to begin your class, you may contact:
Adult classes: +353 87 2790667 | galwayshotokan@gmail.com
Children classes: +353 85 1428669 | galwayshotokankids@gmail.com
Your Karate journey awaits you.