Please read all of the form BEFORE completing and fill in ALL sections using BLOCK CAPITALS

PERSONAL DETAILS
Mr Miss Ms Mrs
First Name
Surname
Address
Post Code
Date of Birth
Tel Number
E-mail
For Official Use Only
Lic No: / Exp:
Code: / Iss:
  1. If you feel that you may have a Medical Condition that may affect your training then you should consult your Doctor and you must inform your Instructor BEFORE undertaking any exercise.
  1. I do not have any medical condition that would prevent me from taking part in strenuous exercise.
  1. I have never been convicted of a violent crime.
  1. I accept that the practice of a Martial Art may involve the risk of injury and it is my responsibility to ensure that I have a valid and up to date Licence.
  1. I do not object to my personal details being held on Computer by the IKC and the Governing Body.

Please indicate any medical condition that you may have:

i.e. Asthma

Signed:______

Parent or Guardian if under 16 years old

Date:______

(Allow 21 days for return of your licence)

LICENCE DETAILS
What licence do you require?
tick appropriate boxes
First / Renewal / Replace lost
Licence (1) / of Licence (2) / Licence (3)
Junior / Senior / Junior / Senior

£25 / 
£25 / 
£25 / 
£25 / 
£10
First Licence (1) only
ENCLOSE ‘TWO’ PASSPORT SIZE PHOTOGRAPHS
(print name on back)
Date started Karate / /
Instructors Name: Sensei -
Club Address:
Licence Renewal (2) only
Previous Licence Number
Grade / Kyu/dan / Date passed
*NOTE: You must send your
Licence book
with your renewal application
Replace Lost Licence Book (3)
Fee for replacement book - £10
If you are renewing your Licence AND need a replacement book, then you must enclose £10 for a replacement book AND the renewal fee:
£25+£10 (total £35)
You will also need to enclose ‘ONE passport photo
Fees
Cheques payable to IKC - check correct fee enclosed
Send completed form & fee to:
Your club instructor
OR
31 Pemberton Gardens
Romford
Essex RM6 6SH

IKC Lic MAY2015