Application to join the Scottish Karate Alliance

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Name *

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Last

Date of Birth

Address *

Postcode *

Telephone Number

Email *

Name of Karate Club

Current Grade (please select)9th Kyu8th Kyu7th Kyu6th Kyu5th Kyu4th Kyu3rd Kyu2nd Kyu1st KyuBlack Belt 1st DanBlack Belt 2nd DanBlack Belt 3rd DanBlack Belt 4th DanBlack Belt 5th DanBlack Belt 6th Dan

Licence RequiredInstructor (new licence book required) £20Instructor (renewal) £16Adult (new licence book required) £18Adult (renewal) £14Child - Under 16 (new licence book required) £14Child (renewal) £10

Have you ever been convicted of a crime of violence or a crime against children? *NOYES

Have you any disabilities or allergies that could prevent you from taking part in physical exercise? *NOYES (please list below)

Additional Medical Information

Application form filled in by *

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Relationship to Applicant *SelfFamilyFriendOther

Factual Statement *

• By clicking here I confirm I have provided accurate information as required.

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YOUR LICENCE IS VALID FOR ONE YEAR FROM DATE OF ISSUE

LICENCE FEES ARE NON-RETURNABLE