HAYASHI-HA
SHITORYU-KAI
MEMBERSHIP APPLICATION
FORM
PLEASE NOTE, ALL APPLICATIONS MUST BE
SUBMITTED WITH TWO PASSOPORT-SIZED PHOTOGRAPHS AND ALL APPROPRIATE
SECTIONS MUST BE COMPLETED. TOTAL OF 4
PAGES
Type of membership required (Tick applicable
box)
1. Individual [ ]
2. Instructor [ ]
3. Club [ ]
SECTION 1 To be completed by (1) and
(2) above
1. Surname
Name(s)
2. Sex
[ ]Male
[ ]Female
3. Date of
Birth
.
ID or Passport
No
.
4. Residential
Address
..
5. Postal
Address
.
6. Tel No
.(W)
(H)
(
7. Email
Address
8. Name of
Employer
..
Occupation
..
9. Employers
Physical Address
..
10. Next of
Kin
.
Tel No
.(W)
(H)
.(Mobile)
Affiliated to:HAYASHI-HA
Post Office
Attn: Pinkie Baleseng (Secretary General)
HAYASHI-HA
SHITORYU-KAI
SECTION 2 To be completed by (3) above
1. Name of
Club
.
2. Contact
Person
. Designation
.
3. Physical
Address of Club
4. Postal
Address of Club
5. Tel
No
..
Fax
.
6. Name of
Instructor
7. ID No
.
Tel No
..(W)
(H)
8. How long has the club existed
.(days/mnths/yrs)
9. Under which
organization or Style
..
SECTION 3 To be completed by all applicants
I/We hereby apply for membership of Hayashi-Ha Shitoryu-Kai and enclose my/our cheque/postal order of
P
. in payment of my/our annual membership fee.
Fees: Individual P20
Instructor P40
Club P100 (subject to change)
[Membership is valid for twelve (12) months from date of
registration]
Signature
Date
Affiliated to:HAYASHI-HA
Post Office
Attn: Pinkie Baleseng (Secretary General
HAYASHI-HA
SHITORYU-KAI
PHYSICAL
ACTIVITY QUESTIONAIRE
Tick the appropriate box
1. Have you trained Karate before? [ ]Yes
[ ]No
2. If answer to 1. is yes, give details
.
...(Which Style, how
long, your grade, Instructors name)
3. Do you take any medication regulary?
[ ]Yes
[ ]No
4. If answer to 3. is yes, give
details
5. Do you experience any chest pains during exercise? [ ]Yes
[ ]No
6. Do you experience dizziness often?
[ ]Yes
[ ]No
7. Do you have high blood pressure?
[ ]Yes
[ ]No
8. Do you have high cholesterol? [ ]Yes
[ ]No
9. Do you have lower back pain? [ ]Yes
[ ]No
10. Do you suffer from diabetes? [ ]Yes
[ ]No
11. Do you smoke? [ ]Yes
[ ]No
12. Are you overweight? [
]Yes
[ ]No
13. Does your chest tighten during exercise (asthma)? [ ]Yes
[ ]No
14. Are there any reasons why you cannot do some
exercises? [ ]Yes
[ ]No
15. If the answer to 14. is yes
give details
.
..
Affiliated to:HAYASHI-HA
Post Office
Attn: Pinkie Baleseng (Secretary General
HAYASHI-HA
SHITORYU-KAI
VERY
IMPORTANT
Please read the following points to ensure a healthier and
enjoyable exercise routine!
1. TRAIN DONT STRAIN. Certain exercises can place strain
on your body if you over do them, you might get
injured.
2. LISTEN TO YOUR BODY. If you are not feeling well,
there is usually a reason. Listen to your bodys warnings and prevent
injury.
3. STRECHING. Any training programme should consist of
warnups, stretching, the main
content, cooling down and stretching again.
4. Report. Please tell your programme leader if you are
experiencing one or more of the following symptoms:
- Pain or uneasiness in the chest, neck,
jaw , legs or arms.
- Breathlessness during
exercise especially when the exercise was easier in the past.
- Dizziness during exercise
or any other unusual pain in your body.
EXCLUSION OF
LIABILITY CLAUSE
I
.. having being advised of and being fully aware of the injuries,
damages and/or loss I may suffer from my practice of Karate and from activities
related thereto, certify that Botswana Hayashi-Ha Karate Union (BHKU) and its
member clubs or personnel, as an organisation or as represented by its
executive, trainer(s), and/or person(s) will not be liable for any injury(ies), damages and/or loss of whatsoever nature which I or
persons under my protection and/or authority may
suffer.
Signature
.
Date
..
Affiliated to:HAYASHI-HA
Post Office
Attn: Pinkie Baleseng (Secretary
General