License Applications

Title
DrMrMissMrs

First Name

Surname

Full Address & Postcode

Email Address

Home Telephone

Mobile Telephone

Date Of Birth

Club
--Select Club--AbergavenyBromyardGt BarrHerefordLeominsterMalvernTenerifeToddington

Is this a License Renewal?
YesNo

License Number

License Expiry Date

Previous Martial Arts Experience

Have you practiced a martial art before? (If yes please specify details)
YesNo

Background

Have you ever been convicted of a criminal offence. All information will be treated in the strictest confidence.
YesNo

Photography

I understand that IMAE and its Instructors may at times make use of photographic images of IMAE members for the promotion and / or the teaching of Taekwondo.
YesNo

Medical Notes

Do you suffer from any medical conditions? If YES please give further details in the box below? (Optional) Example; Asthma, Diabetes. All information will be treated in the strictest confidence.