Membership Form

Name *

NOTE: For insurance purposes, the applicant's Forenames & Surname MUST be the same as on Birth Certificate!

First Name

Last Name

Date of Birth *

day, month, year

MM

DD

YYYY

Applicant Phone Number

Applicants under 18 yrs old: By putting your child’s contact number, you consent for NWAC to contact them via their contact number..

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Parent/Guardian Name *

Emergency Contact 1

First Name

Last Name

Parent/Guardian Phone Number *

Emergency Contact 1

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Emergency Contact Name *

Please provide the name of an ADDITIONAL emergency contact

First Name

Last Name

Emergency Contact Phone Number *

Please provide a phone number of an ADDITIONAL emergency contact

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Membership application *

New Member

Renewal

Acknowledgement: I apply for one year's membership with NWAC and agree to comply with the rules and procedures of NWAC. I acknowledge that I have read and understood the section 'Health Risks in the Practice of Taekwondo & Hapkido' and accept that there is a risk of injury through the practice of Taekwondo & Hapkido. I have read the 'Publicity Release' and agree to the terms of the release. I understand that it is my responsibility to provide NWAC with information about any medical disorders, that I have, that may affect my ability to practice Taekwondo/ Hapkido and that failure to do so may invalidate my insurance cover. I also understand, that by including the email and contact number of applicants under the age of 18, I consent for NWAC to contact them using both these methods. I have read and agree to act according to the 'NWAC Student code of conduct'. Personal Data: Your personal details are being collected for Contractual, Insurance, Club communication/ announcements and for Marketing purposes only. We are obliged to share your data with the Insurer for insurance purposes. This is for your protection. By ticking 'Agree' you consent to this necessary use of your personal data as delineated above, without which, for legal reasons, we cannot provide you with a service. *

*It is necessary to click agree otherwise we cannot accept your application.

Agree

Name of person signing the agreement *

First Name

Last Name

Date *

MM

DD

YYYY

Payment Type *

Be reminded, if paying by transfer, use ref: Student Initial & Surname/ MEM. E.G: P. Jones, MEM

Cash

Bank Transfer

Via Website (Below)