Full Name:

DOB:

Occupation:

Address:

Email:

Phone:

Day(s) Attending

Monday

Wednesday

Both

Please specify any current medical conditions or injuries:

Previous experience in self defence, combat sports or martial arts:

How did you find out about us?:

Reason for wanting to do Krav Maga eg: fitness, practical self defence skills, self confidence…:

Emergency Contact Name:

Emergency Contact Number:

Assumption of Risk: Waiver

I hereby apply to enrol for Krav Maga self defence training. I have been fully informed of the nature of the training and the physical risks involved. I accept all risks involved in training and agree not to hold Krav Maga Canberra, its instructors, staff members and students, Krav Maga Global and its instructors, staff members, proprietors, owners, managers or any staff member of training establishments, that may be used on a permanent or semi-permanent nature, liable for any injuries sustained in connection with my participation in Krav Maga training. Further, I have no medical condition or other physical impediment that would preclude me from participating in this training which involves robust physical activity. In the event that I may need medical assistance due to injury or illness whilst or as a result of training Krav Maga I hereby give full consent to Krav Maga Canberra or any of the above mentioned instructors to, if required contact ambulance or other relevant medical assistance on my behalf. I understand and accept that Krav Maga Canberra or Krav Maga Global do not provide any medical or accident cover for myself and that I am liable for any costs incurred due to ambulance or other medical assistance required at any time either now or in the future as a result of training krav Maga.

I accept the terms and conditions outlined above:

Yes

No

Security – Insert numbers from image above:

Are you registering more than one person?:

Yes

No