Taekwondo Signup - Fighting Lyons

Taekwondo Member Form

Student Details
Student Name*
Prefix First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
DD slash MM slash YYYY
Contact Phone Number*
Occupation*

e.g. retail assistant, student
Contact Email*
Consent & Liablity
Consent*
I agree to the following:
I confirm that I have been notified of the Terms and Conditions involved in commencing a Taekwondo membership with Fighting Lyons (aka Southern Gyms Pty Ltd), and I acknowledge that at all times whilst on the Fighting Lyons premises or on premises used by Fighting Lyons, both my person and my property shall be at my own risk. I will not hold Fighting Lyons or Southern Gyms Pty Ltd liable for any damages to person or property.
Student Name (Over 18)
I acknowledge that this name will act as a digital signature.
Prefix First Last
Parent or Guardian Name (Under 18)
I certify that I am the Parent/Guardian of the following individual:
Child First Name Child First Name
(Continued)
I consent to him/her/them participating in classes, activities and events with Fighting Lyons aka Southern Gyms Pty Ltd. By entering my name below, this submission will act as a digital signature.
Prefix Parent/Guardian Name Parent/Guardian Name
Medical Information & Emergency Contact
In case of emergency, please contact:
Emergency Contact #1: Name*
First Last
Emergency Contact #1: Phone Number*
Emergency Contact #1: Relationship to Student*
Emergency Contact #2: Name*
First Last
Emergency Contact #2: Phone Number*
Emergency Contact #2: Relationship to Student*
Please list any Pre-existing Medical Conditions
Please also include any treatment details e.g. inhaler, Epipen

Taekwondo Insurance Form

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

Taekwondo Member Form

Student Details

Consent & Liablity

Medical Information & Emergency Contact

Taekwondo Insurance Form

Organisation Information

Individual Membership Insurance

Taekwondo Background

Declaration

Insurance Payment