Higashi Karate Kai

LICENCE APPLICATION FORM

TICK TICK
SENIOR LICENCE (16+) @ 20.00 IS THIS YOUR FIRST HKK LICENCE? YOUR CLUB NAME YES NO JUNIOR LICENCE (-16) @ 16.00 IF YES, DATE YOU BEGAN TRAINING?

EXIST ING
PREVIOUS LICENCE NUMBER CURRENT KARATE GRADE

MEMBERS

MUST

COMPLET E

T HIS

SECT ION

FULLY

EXPIRY DATE OF PREVIOUS LICENCE CLASS DATE OF LAST GRADING

NAME OF CHIEF EXAMINER FOR LAST GRADING

I F Y O U A R E A N I N S T R U C T O R, Y O U M U S T C O M P L E T E T H I S S E C T I O N
PROFESSIONAL INDEMNITY NUMBER EXPIRY DATE OF POLICY

ALL MEMBERS MUST COMPLETE THE

FOLLOWING SECTIONS

HAVE YOU SUFFERED, OR DO YOU SUFFER FROM PROBLEMS WITH ANY OF THE FOLLOWING (DELETE WHERE NOT APPLICABLE) BLOOD HEART YES YES NO NO KIDNEYS RESPIRATION YES YES NO NO LIVER EPILEPSY YES YES NO NO

IF ANY OTHER OR INJURY PLEASE SPECIFY DESCRIBE ANY MEDICATION BEING TAKEN OR TREATMENT BEING RECEIVED HAVE YOU EVER BEEN CONVICTED OF A SERIOUS CRIME OR OFFENCE OF VIOLENCE IF YES, PLEASE GIVE DETAILS YES NO

PLEASE
TITLE MR MRS ADDRESS MS

COMPLETE
FIRST NAME

THE

FOLLOWING

IN

PRINT
SURNAME

AND

CLEARLY

POST CODE TELEPHONE NUMBER E-MAIL ADDRESS (if any) OCCUPATION (if employed)

DATE OF BIRTH

PLEASE TURN TO REVERSE SIDE AND COMPLETE THIS FORM

IMPORTANT - PLEASE READ

This licence incorporates a personal insurance and weekly benefit in the case of injury. Your personal insurance is invalid if you do not possess a current EKF/HKK licence, and any claims you may have had would be invalid. It is recommended therefore that your EKF/HKK licence be renewed before the expiry date. HKK will not be held responsible or liable should your expired licence result in legal action against you. Incorrectly completed forms will be returned unprocessed. Applications received without an s.a.e. will be withheld until the end of the month, then sent to your club secretary. Should your licence be expired, any grade awarded to you during the expired period will not be recognised. If you are an instructor with an expired or suspended licence, any grades awarded by you to any HKK member will not be recognised and will be declared void. If unlicensed, you are not a member of HKK and therefore cannot train or instruct.

CONSTITUTION

RULE

Members of Higashi shall, to the best of their ability strive to be a credit to the Organisation and not to engage in, nor be part of, any action which may, by its nature, bring Karate or Higashi into disrepute. I agree and understand that I may be subject to Criminal Records Bureau (CRB) checks at any time during my membership of HKK. I affirm that the information given is accurate and that I shall comply with the Constitution of H.K.K.
Members Signature (parent if aged -16) Secretarys/Instructors Signature Dated:

NOTE:

A copy of the HKK Constitution is available from your club instructor and is also published on our webpage at: www.higashi.org.uk.

PLEASE COMPLETE THIS FORM CORRECTLY AND FULLY WHERE APPROPRIATE, AND SEND WITH THE RELEVANT FEE PLUS A S T A M P E D S E L F - A D D R E S S E D E N V E L O P E TO: The H.K.K. Registrar Oak Haven Tatsfield Avenue Nazeing ESSEX EN9 2HH CHEQUES / P.O's PAYABLE TO H.K.K. === I M P O R T A N T N O T E ===
IF A NEW MEMBER, YOU SHALL NOT BE ELIGIBLE TO GRADE UNTIL YOU HAVE HELD AN HKK LICENCE FOR AT LEAST 3 MONTHS.

===== THE FORMAT OF THIS FORM MUST NOT BE ALTERED IN ANY WAY =====