Membership Form

Membership Type

I am applying for a*

Single Membership at £49 per month
Combined Membership 2 Family Members at £88 per month
Combined Membership 3 Family Members at £120 per month
Combined Membership 4 Family Members at £140 per month
Combined Membership 5 Family Members at £150 per month

Please indicate the Dojos you will be attending*

Eastleigh - Places Leisure Centre
Chamberlayne Leisure Centre
Bitterne Leisure Centre
Winchester Sport & Leisure Park
Hatch Grange Outdoors
Holly Hill Leisure Centre

Member's Information

Name*

First Last

Pronoun*

Date of Birth*

Name*

First Last

Pronoun*

Date of Birth*

Name*

First Last

Pronoun*

Date of Birth*

Name*

First Last

Pronoun*

Date of Birth*

Name

First Last

Pronoun*

Date of Birth

Parent / Guardian (if under 16)

Prefix First Last

Optional 2nd Parent / Guardian (if under 16)

Prefix First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email Address*

Enter Email Confirm Email

Alternative Email Address

Optional

Enter Email Confirm Email

Contact Number*

Alternative Number

Medical and Emergency Contact

Medical Conditions*

Do you have any medical conditions or allergies we should be aware of:

No
Yes

About Your Medical Condition(s)*

Emergency Contact Name

First Last

Emergency Contact Number

Payment

Payment*

Securely pay for your subscription via credit or debit card.
You hereby authorise Kyudokan to set up a continuous monthly payment on the card entered below for the selected fees pertaining to this membership.

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Card Details

Cardholder Name

Monthly Membership*

I understand that cancelling the membership is subject to a 1 month notice period.

Declaration*

I am aware and accept that the practice of martial arts involves the risk of injury and that I agree to abide by the association rules.

Photograph / Video Consent*

Please can you confirm your approval below for club photos to be taken during events, which may be used on our website, social media, or for promotional literature:

Yes I am happy for this
No please do not include me in this

Phone

This field is for validation purposes and should be left unchanged.

Kyudokan Goju Ryu Karate Do

Membership Form - New Members

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