Irish Judo Association
Application for Individual Membership 2018
All renewal memberships become due the 1st of January each year
Full Name: ______
Address: ______
______
Phone No: ______Mobile No: (if over 18yrs) ______
Email Address: (if over 18yrs) ______Date of Birth: ______
Club Name: ______Sex (M/F):______
Please tick which applies: JUNIOR DAN GRADES MUST APPLY FOR SENIOR LICENCE
Under 12 €25:______Under 18 €35:______Over 18 €55:______Life Member €10: ______
Student €40: ______School Club €25:______
Membership No: ______Grade: ______
New Member: ______Renewal Member: ______
(please tick X) (please tick X)
Adapative Judo: Y/N______Disability:______
This section to be completed by Parent/Guardian if applicant is under 18 years of age.
Full Name: ______
Email Address: ______Phone No: ______
This information may be used to keep parents/guardians up to date with events, offers and general information regarding Judo and will not be shared with any third parties. If you do not wish to receive any information electronically please tick the box:
Declaration to be completed by applicant/Parent/Guardian
I certify that to the best of my knowledge & belief the foregoing details are correct. I undertake to abide by the constitution & Bye-Laws of the Irish Judo Association together with any amendments that may be made during my period of membership. Please note the policy of ‘No Licence - No Insurance - No Judo’ is in force & cost of personal accident insurance is included in the above categories. Personal information gathered for the purpose of individual membership is handled in accordance with the requirements of the Data Protection Act. I further confirm that I am not a member of any other Judo Federation. I will adhere to the Irish Anti-Doping rules.
Signed: ______Date: ______
Club Consent
I agree to accept the above named person as a member of ______Judo Club.
Signed: ______Date: ______
Return Address:
Irish Judo Association,Irish Sport HQ,National Sports Campus,Abbotstown, Dublin D15 DY62
Irish Judo Association
Irish Sport HQ, National Sports Campus, Abbotstown, Dublin, D15 DY62
Tel: 01 6251104 Email:
Company limited by Guarantee. Registration No. 112335.
V.A.T. Reg No. IE4806869B
President: Mr Seán Fleming