Registration Form for New StartersThis must be completed before the student starts training! Full Name * If completing for someone under 16 years old, please complete all details below for the individual attending the session, unless otherwise stated. First Name Last Name DoB * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * If completing for someone under 16 years old, please use authorising adult's contact details. (###) ### #### Email * Emergency Contact * First Name Last Name Emergency Contact Number * (###) ### #### Medical Issues? * Click all that apply. Please note that none of the following are necessarily disqualifying. N/A Cardio-vascular conditions (e.g. angina) Lung disease / breathing problems (e.g. asthma) Neurological issues (e.g. epilepsy, migraines, blackouts) Joint problems / long-term injuries Diabetes Chronic transmissible disease (e.g. HIV, Hep C) Neurodivergence (e.g. ADHD, autism) - suspected or confirmed Is the attendee pregnant, or possibly pregnant? * Due to the physical nature of Krav Maga training, training while pregnant is NOT advisable. Yes No Any other conditions which may affect your ability to train safely? (Please specify) * If not relevant, enter 'N/A' Any you using any medication that may affect your ability to train safely and/or may be required in an emergency (please specify) * If not relevant, enter 'N/A' Does the attendee have any unspent criminal convictions for violence? * Yes No Is the attendee (OR, for under 16s, the authorising adult), OR any organisation to which they belong, an enemy of, or otherwise hostile to, the State of Israel? * Yes No Does the attendee (OR, for under-16s, the authorising adult) give Pentagon Krav Maga permission to contact them for marketing purposes? * Yes No Does the attendee (AND, for under-16s, the authorising adult) give Pentagon Krav Maga permission to share photos featuring the attendee to public platforms (social media, website, etc)? * Yes No The attendee (OR, for under-16s, the authorising adult) confirms they have read, and agree to, Pentagon Krav Maga's Terms & Conditions * Yes No The attendee (OR the paying adult for under-16s) confirms that a direct debit has been set-up on GoCardless to enable future payments. * Yes No How did you hear about us? Facebook Instagram Google Poster / print media Word-of-mouth Other What do you want to get out of training? Select all that apply. Self-defence skills Fitness Confidence Discipline Just curious! Other Which class/es do you want to attend? * Select your most-likely future option/s. This does not lock you into a particular class! Monday - Kettering Tuesday - Desborough Juniors Tuesday - Harborough Thursday - Desborough Juniors Thursday - Harborough Sunday - Desborough Adults Sunday - Ladies-only Full Name (authorising adult) * Use only if completing registration for someone under 16, otherwise just re-enter your name. First Name Last Name Thank you for completing your registration!We look forward to seeing you soon! See our Terms & Conditions here Follow this link to set-up the direct debit
