Konjaku Shin Membership Application Form



		INDIVIDUAL MEMBERSHIP FORM
	(Name) ............................................................................................................................................................................................. herewith applies for membership of the Konjaku Shin National School of Karate for the year: 2 __________ Annual Membership fee: SENIOR: (over 16) £GB59.00 JUNIOR: (under 16) £GB49.00 Please make Cheque/Banker's Draft payable to: KONJAKU SHIN. NAME ................................................................................................................................................................................................ ADDRESS .......................................................................................................................................................................................... ........................................................................................................................................................................................................... ZIP/POST CODE ............................................................................. COUNTRY .................................................................................. DATE OF BIRTH ................................................................................................................................................................................ OCCUPATION..................................................................................................................................................................................... TELEPHONE NUMBER: ............................................................... FAX .............................................................................................. EMAIL ADDRESS ............................................................................................................................................................................... The Konjaku Shin National School of Karate reserves the right to cancel the membership of any member without re-imbursement, should that member misuse the techniques of Karate-do, or in any way bring discredit to Konjaku Shin or Karate-do. The applicant acknowledges and accepts the membership and training fees, and conditions of membership detailed above, with his / her signature, and confirms that he / she has no criminal convictions. IMPORTANT If you suffer from any illness or condition which could affect your participation in karate training please give full details on the reverse of this application form, together with full details of any medication used. SIGNATURE OF APPLICANT/PARENT OR GUARDIAN IF UNDER 18. ......................................................................................................................................................... PAYMENT METHOD Cheque Postal Order Cheques crossed please and made payable to Mr D. Kershaw CREDIT/DEBIT CARD All major Cards including: VISA, MASTERCARD, JCB, DELTA, SWITCH, SOLO, Card Type (eg: Visa/Mastercard) .......................................................................................... Card Number ...../...../...../...../...../...../...../...../...../...../...../...../...../...../...../...../ Valid from .... /.... /.... /.... / Expiry Date ..... /.... /.... / .... / Security Number .... /.... /.... /..../ Switch Issue Number .... /.... / PLEASE COMPLETE AND MAIL TO: SENSEI DAVE KERSHAW 6th Dan. KONJAKU SHIN NATIONAL SCHOOL OF KARATE LOWER SPRING STREET, GRIMSBY, LINCOLNSHIRE, ENGLAND DN31 3JS.