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Please fill in this form for ALL karate licence applications or renewals

Full name
Title
Full Address
Home phone
Mobile telephone
E-mail
Date of birth
What class/club do you attend?
Criminal convictions
yes
No
Do you suffer from any of the following
Haemophilia
Diabetes
Epilepsy
Asthma
Migraine
Nervous disorders
Please state any health concerns or requirements
Licence type applying for
Junior new application
Junior renewal
Schools/concessionary new application
Schools/concessionary renewal
Senior new application
Senior renewal
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I agree to the above message
Yes
No
Licence will only be processed on agreement to terms and conditions
What is the Primary purpose for you learning the Martial Arts?
Description (click to edit)
if 'other', please tell us here
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