Craigieburn Martial Arts Centre

HOME
CLASSES
- Judo
- Jujutsu
- Iaido
- Jodo
INSTRUCTORS
MEDIA
INFORMATION
CONTACT
MEMBERS
- Login
- Membership Application

Menu

HOME
CLASSES
- Judo
- Jujutsu
- Iaido
- Jodo
INSTRUCTORS
MEDIA
INFORMATION
CONTACT
MEMBERS
- Login
- Membership Application

Membership Application

Membership Type*

Single Adult

Family

How many children?*

1

2

3

4

First

Last

Phone*

Email*

Date of Birth*

day

/

month

/

year

Gender*

Male

Female

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Medical History

Father’s Name

First

Last

Father’s Phone

Father’s Email

Is father attending class?*

Yes

No

Father’s Date of Birth*

day

/

month

/

year

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Father’s medical history

Mother’s Name

First

Last

Mother’s Phone

Mother’s Email

Is mother attending class?*

Yes

No

Mother’s Date of Birth*

day

/

month

/

year

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Mother’s medical history

Child 1 Name*

First

Last

Child 1 Date of Birth*

day

/

month

/

year

Child 1 Gender*

Male

Female

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Child 1 medical history

Child 2 Name*

First

Last

Child 2 Date of Birth*

day

/

month

/

year

Child 2 Gender*

Male

Female

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Child 2 medical history

Child 3 Name*

First

Last

Child 3 Date of Birth*

day

/

month

/

year

Child 3 Gender*

Male

Female

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Child 3 medical history

Child 4 Name*

First

Last

Child 4 Date of Birth*

day

/

month

/

year

Child 4 Gender*

Male

Female

Illness / Injuries / Other Relevant Information
(Any previous or current illnesses, injuries, ailments (for example, asthma), inherent dispositions, operations, medical procedures or sporting injuries that may affect performance or ought to be considered):

Child 4 medical history

Address*

Street Address City Post Code

Emergency Contact*

Parent

Other

Emergency Contact Name*

First

Last

Relationship

Emergency Phone*

Name of person submitting form*

First

Last

Submitter’s Email*