2 photos required with license application!

MEMBERSHIP ACTIKARATE
Photograph APPLICATION FORM
TO BE COMPLETED IN BLOCK LETTERS (see over leaf for guidance notes)

SURNAME Completed Applications to:

INSTRUCTOR WITH
MR / MRS / MISS / MS EXISTING LICENCE
CHRISTIAN NAMES Cheques payable to
ACTIKARATE
ADDRESS

TEL NO DATE OF BIRTH CLUB

OCCUPATION NATIONALITY

ANY MEDICAL CONDITIONS

YES / NO (Please circle)
TYPE OF
CONDITION_____________________________________________________________________

WORK ADDRESS

WORK TEL.NO
I REQUIRE :
Photograph
* 1 YEARS MEMBERSHIP FROM DATE OF RENEWAL FIRST APPLICATION
* Junior Licence… £15.00 5 - 15 yrs age
Senior Licence… £18.00 Over 16 yrs of age RENEWAL
DETAILS OF LAST GRADING
Date Place of Examination Grade Awarded Examiners Name

DECLARATION TO BE COMPLETED BY APPLICANT

I certify that to the best of my knowledge and belief, the foregoing details are correct, and in the event of my being
accepted, I undertake to abide by the constitution and Bye-Laws together with any amendments that may be made during
the period of my membership.

Signed ………………………………………………………………………………… Date …………………………………………….

Signature of Parent or Guardian …………………………………………………… Date …………………………………………….

(if applicant is under 16)
 NOTES FOR GUIDANCE

1. Applications must be filled out clearly in BLOCK LETTERS.

2. Under DETAILS OF LAST GRADING if you have not been graded before, enter “Ungraded” in
the Grade column.
N.B. If you have been awarded a temporary grade, place a “T” at the end of the grade.
3. Cheques and Postal Orders should be made payable to ACTIKARATE. only.

First applications
1. One photograph must be attached to the application form
2. One photograph must be enclosed for the licence.
3. Your name must be printed on the reverse side of each photo.

Renewal of Licences
Licences to be renewed annually.
Period of Licence to run for 12 months from date of application.
Please send existing licence together with completed application form (no photograph required)
and appropriate fee.
All Applications:

Please state in the appropriate section if you have any medical conditions that the Association needs to be aware
of. (Please tick where appropriate and state condition)

Please note:
14 clear days should be allowed when sending in your Application Form for it to be processed and returned.

All Dan grades must take out personal Instructors Liability Insurance in order to teach, instruct, referee and/or
examine students for ACTIKARATE. It is the responsibility of the Dan grade to ensure that his insurance is
renewed and (s)he has continuous cover for teaching, instructing, referee and examining students within
ACTIKARATE.

If you have a medical condition or one has arisen since the last time you completed this form please confirm this
by filling out the section overleaf with regards to Medical conditions. In such cases you may be asked to produce a
medical consent from your GP approving your practice of Karate.

The association reserves the right to terminate the application of any student it sees misusing, or undermining the
authority of the Association through training, coaching, examining and teaching.

It is the responsibility of the student to renew their membership in order to have continuous cover for training. We
will however send out reminders.

PLEASE RETURN TO
‘ACTIKARATE’
55 SHORTMEAD STREET
BIGGLESWADE
BEDS
SG18 0AT

www.actikarate.com