TAEKWONDO INSURANCE 2022

Hidden
Organisation Information
Hidden
Club/Organisation Name
Hidden
Principal Instructor Name
Hidden
Organisation Contact No.
Individual Membership Insurance
12-month coverage, annual fee, all ages, 1 Feb 2022- 31 Jan 2023
Student Name*
First Last
Student Date of Birth*
DD slash MM slash YYYY
Student Nationality*
Student Gender*
Student Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone Number*
Contact Email*
Taekwondo Background
Current Rank

e.g. 3rd poom
Kukkiwon Rank (if applicable)

e.g. 1st poom
Number
Declaration
I hereby wish to apply for membership of TKD - Sports Taekwondo Australia and acknowledge that I do so of my own free will. acknowledge that I am subject to the Statement of Purposes and Rules of TKD - Sports Taekwondo Australia and its policies, regulations and by-laws.
Student Name (Digital Signature)*
First Last
Confirm Student Name (Digital Signature)*
First Last
Dated*
MM slash DD slash YYYY
Name of Parent/Guardian (if under 18 years) (Digital Signature)*
First Last
Dated*
MM slash DD slash YYYY
Contact Number*
Insurance Payment
1 Year Insurance*
Total
A$ 0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Organisation Information