Do you suffer from any of the following? If YES, please tick the appropriate box

Affiliated to the Independent Traditional Karate Organization (ITKO)
               & the English Traditional Nunchaku Association (ETNA)
 

To be completed in BLOCK LETTERS      (First Licence & Annual Renewal Licence £30.00)
                                                                                       Cheques payable to: ‘Seishinkai’
 

SSKI LOGO ON WHITE
ITKO logo from home page

 Surname:

 First name(s):

 Date of birth:

 Male / Female:

 Address:

 

 

 

 Post code:

 Telephone Number:

 Email address:

 Contact number (for emergencies):

 Migraine

 

 Epilepsy

 

 Hay Fever

 

 Diabetes

 

 Heart conditions

 

 Haemophilia

 

 Nervous disorders

 

 Respiratory problems (e.g.   Asthma)

 

 HIV/AIDS or Hepatitis

 

 Do you wear contact lenses?

 

Have you ever been convicted of a crime of violence?                  YES / NO

 Please give brief details if answered YES to the above.

PTO

LICENCE APPLICATION FORM

SEISHINKAI SHOTOKAN KARATE INTERNATIONAL (SSKI)

LICENCE APPLICATION FORM continued….

Have you ever trained in a Martial Art before?                             YES / NO

If answered YES please give details below:
 

If you have listed previous experience or grades within Shotokan Karate, or any Karate Referee or Coaching qualifications please attach evidence of these to this application (e.g. copies of certificates or licence entries)

Declaration:

I the undersigned, confirm that all of the information provided above is accurate and true. I understand that any false information provided, will invalidate my membership and may lead to expulsion from the Association. I also agree to abide by the SSKI and Karate codes and I agree
not to use my art except in the defence of my family and friends and law and order.

 

Signed:    ......................................................          Date:     .....................................



 

This form and any accompanying certificate evidence must be completed and returned as soon as possible to your club Instructor with the correct remittance fee. Your Instructor reserves the right to decline an application without giving reason.
 

Parent or guardian if under 18yrs of age

For office use:

Application accepted:  YES/ NO          Date: accepted: ....................  By:  ....................
 

Grade proof obtained: YES / NO         Verified:     YES / NO

First SSKI licence number: ............................

 Type of Martial Art (i.e. Karate, Judo etc.)

 

 Style:

 Club or Association (i.e. KUGB, BJJA etc.)

 

 Instructor:
 

 Number of years trained:

 

 Highest grades obtained (e.g.3rd Kyu, 2nd Dan)

 Examiner:


 Date of highest award:

 Place of examination:

 

 Other qualifications (e.g. Referee, Coach)