Kazen Kai Temporary Membership System- new member

Please fill out this form with the details of the student starting the course/class

First Name

Please enter a first name

Last Name

Please enter a last name

Address

Postcode

Date of Birth (dd/mm/yyyy):

Membership Type

Karate

Kick Boxing

Taekwondo

Fitness

Phone No

Preferred Club

Gender

Male

Female

No Yes 1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?

No Yes 2) Do you feel pain in your chest when you do physical activity?

No Yes 3) In the past month, have you had chest pain when you were not doing physical activity?

No Yes 4) Do you ever feel faint, lose your balance due to dizziness or lose consciousness?

No Yes 5) Do you have a bone or joint problem (for example arthritis, back, knee, or hip) that could be made worse by physical activity?

No Yes 6) Has your doctor ever said that your blood pressure was high or low?

No Yes 7) Are you or have you been pregnant in the past 6 months?

No Yes 8) Are you currently taking any medication ?"

No Yes 9) Are you aged 69 or over and not used to physical activity?

No Yes 10) Do you know of any other reason why you should not participate in a physical activity programme?

IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS ABOVE OR HAVE FURTHER NOTES PLEASE COMMENT BELOW :

For the avoidance of doubt, neither Kazen Kai nor any of its employees and/or agents accept liability for any injury caused to you where such injury is the result of your failure to seek qualified advice from a Doctor or Medical professional before starting physical activity at the club."

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If you are happy confirm and submit completed details