YOUR DETAILS
Student Name

Date of Birth for person to be insured

Your Email address (required)

Male or Female (please select, required)
MaleFemale

Address

Postcode

Contact Telephone number

Which one of our classes do you attend most regularly?
---Staines - SundayStaines - WednesdayHeston - SundayHeston - TuesdaySunbury - FridaySunbury - SaturdayCharlton Village - Friday

Medical History
PLEASE OUTLINE ANY MEDICAL ISSUES THAT MAY AFFECT YOUR CHILDS TRAINING, PLEASE ALSO INFORM YOUR LEAD INSTRUCTOR DURING EACH CLASS OF ANY ONGOING ISSUES.

INSURANCE ACCEPTANCE
Signature/Acceptance, please check this box as acceptance of the terms of our insurance

PHOTO USAGE CONSENT
Occasionally, we may take photographs and video of the students at our club and external events where we compete. We use these images as part of our marketing and social media activity, as well as printed publications to promote Shentie Martial Arts Academy. We will also use them on our website, Facebook page and Twitter and Instagram pages. If we use photographs of individual students, we will not use the name of that child in the accompanying text or photo caption. If we name a pupil in the text, we will not use a photograph of that child to accompany the article. If a child has won an award and the parent would like the name of their child to accompany their picture we will obtain permission from the parent before using the image.

I give permission for my child’s image to be used for marketing purposes on our website, social media outlets and printed materials.

CONTACT CONSENT
I give consent for Shentie Martial Arts Academy to contact me.

Once you submit this form, you will be redirected to PayPal, child insurance is currently £29.95 for 1 year.