MUSKC Membership Application & Medical Declaration
In order for you to participate safely in the activities we have planned, we require the following questionnaire to be completed in full.
Any changes in your medical or physical condition from the time of completing this form will require you to inform the club officials and complete a new form. We understand this information is sensitive, so just fill in as much as you are comfortable providing.
Student Information
FULL Name *
Please enter both first name and last name together.
Your answer
Student Number (If applicable) *
This will be the number on your library card.
Your answer
Email Address *
Your answer
Date of Birth *
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Address *
Please use your current address (student halls of residence is OK.)
Your answer
Postcode *
Your answer
Phone Number
Your answer
Emergency Contact Full Name *
Your answer
Emergency Contact Relation *
Mother, Partner, Housemate etc.
Your answer
Emergency Contact Phone Number *
Please enter the main phone number of your emergency contact.
Your answer
Emergency Contact Email Address *
Please enter the main email address of your emergency contact.
Your answer
Emergency Contact - Additional Information
Please enter any additional information about your emergency contact them, such as other phone numbers, the best time to contact, place of work etc.
Your answer
Date of Application *
Today's date.
MM
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DD
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YYYY
Karate License Information
Do you hold any grade with a Karate association or organisation? *
Required
Please enter your current Karate grade (If applicable)
Include your Shotokan grade (if applicable) or grade from another style
Your answer
Please enter your KUGB License Number (If applicable)
Your answer
Please enter your KUGB License expiry date (If applicable)
MM
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DD
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YYYY
Please name any other association or organisations you are, or have previously been a member of (if known)
Your answer
Medical Information
Any medical information taken on this form will be treated securely and confidentially. We understand this information is sensitive, so just fill in as much as you are comfortable providing.
This information will help provide understanding of any conditions that may inhibit your training, so that we can make provisions for helping you overcome any problems or issues so that you continue to progress and improve to the best of your ability.
Doctors Name (If known)
Your answer
Doctors Address (If known)
Your answer
Do you take any type of medication for any medical condition? *
Please provide information, however minor your condition.
Required
If yes, please state the condition and the medication prescribed
Provide as much information as you are comfortable with, it will only be shared with the committee and if appropriate your instructors. If you wish to discuss this face to face instead, just leave a note to let us know.
Your answer
Do you have Asthma? *
Inhalers or medication must be carried during all activities
Required
Are you prone to any of the following? *
Please select all options that are appropriate.
If you ARE prone to any of the options above, please provide any helpful information.
Your answer
Do you have any abnormal heart condition, or are you taking medication for a heart condition? *
Required
If yes please give details of condition and medication
Your answer
Do you experience any of the following during or after physical activity? *
Don't worry, this won't stop you training, but will help us make provisions for your health and safety.
If you DO experience any of the above, please provide any helpful information
Your answer
Do you have any bone or joint problem that could be aggravated by physical activity? *
Required
If you DO have a bone or joint problem, please provide any helpful information
Your answer
Are you aware through your own experience, doctor’s advice, or from any other source as to why you should not take part in karate or any physical activity without medical approval? *
Required
If you DO have reason for the above, please provide any helpful information
Your answer
Do you suffer from any serious medical condition, allergy, or disease? *
Required
If you DO suffer from any serious medical condition, allergy or disease please provide any helpful information
Your answer
Consent Information
Statement of consent for recording of images and storage of Personal information of the member As an integral part of the club’s activities, you will have the opportunity to participate in the full range of events organised by and on behalf of the club members, i.e. grading’s, tournaments, social events. Images recorded by or on behalf of the club may be released to the local press or to our approved web site for promotional purposes only. These images will be used by the club in accordance with the strict protocols that are in force. The Club and its Officers have no control over images recorded at public events. Details of members are provided to the KUGB on request in order to secure insurance cover. This may take the form of paper or electronic storage. Your consent is required before any image can be taken of you for official publications *
Required
Do you consent to any necessary emergency medical treatment being given to you whilst a member of the club? *
Required
If you do not consent please advise the course of action to be taken in this event
Your answer
I agree to my participation in the activities of the Manchester University Shotokan Karate Club & The KUGB or other karate organisation. I fully understand that my participation in the activities of this club or others, may involve vigorous physical contact with other members during training or competition, this contact may include all forms of strike, sweeps or throws to the body. Whilst every effort will be made for students to control the level of contact, I understand that from time to time injuries can occur as a normal part of my participation in the club. I sign this membership form in the full knowledge of the risks involved in the participation of karate and its related activities. *
Required
Do you need a gi?
If YES, choose your height group.
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