Student Forms Please familiarise yourself with the website menu links and read the information available on the following pages to get a good understanding of Close Combat Martial Arts before filling out this form; Assumption of Risk Notice, FAQ, Club Charter, Club Rules, Club Principles, Club Grades, Our Safeguarding Policy. BASIC INFORMATION Full Name(required) Date of Birth(required) Mobile Number(required) Home Number Email(required) Do you want to subscribe to email updates? Yes No Height(required) Weight (optional) Gender Male Female Other EMERGENCY CONTACT INFORMATION Emergency Contact(required) Who is this person to you?(required) Emergency Contact Number(required) Secondary Emergency Contact Number MEDICAL HISTORY History of heart problems? (Chest Pains, heart murmur or stroke)(required) Yes No Diabetes?(required) Yes No Asthma, breathing or lung problems?(required) Yes No Allergies?(required) Yes No Cancer?(required) Yes No Seisures, seizure medication,nuerological problems or dizziness?(required) Yes No High blood presure?(required) Yes No Recent surgery? (past 12 months)(required) Yes No Hernia or any condition that may be agrivated by exercise?(required) Yes No Previously recieved advice about exercise?(required) Yes No History of high colestorol?(required) Yes No Family history of corony heart desease?(required) Yes No Do you smoke tobacco products?(required) Yes No Do you consume excessive alcohol?(required) Yes No Do you take suppliments of any kind?(required) Yes No Are you on any medication?(required) Yes No Back problems, joint or muscle disorder still effecting you?(required) Yes No Do you have any skeletal injuries?(required) Yes No Excessive stress, depression anxiety or sleep disorder?(required) Yes No If you answered yes to any of the above, please consult your doctor by phone or in-person before you start your martial arts training. Tell your doctor about this medical questionnaire, which questions you answered yet too and get advice about how to moderate your exercise during training. Please provide us details of any of the above issues and any advice you've been given so that we can accommodate your needs. FITNESS LEVEL AND GOALS What are your fitness concerns or goals?(required) Weight loss Strength Power Endurance Cardio fitness Flexibility Agility Balance How long has it been since you have exercised regularly?(required) Do you participate in any other sports or physical training regularly?(required) Do you have any martial arts or self defence experience?(required) STATEMENT OF TRUTH I have truthfully filled out the personal information, medical history and fitness level and goals forms to the best of my knowledge at this current time.(required) Yes I understand CCMA is covered with public liability insurance and I will get student insurance, I will take every precaution necessary to maintain my own health and safety, taking advice from my doctor and instructor seriously.(required) Yes I understand that I have to follow instructions carefully, to exercise control whilst learning at a steady pace for my own and my training partner's skill level and take care not to cause harm to other students.(required) Yes I confirm that I understand in full that any activity in which I participate will carry inherent risks associated with any practice or competition within combat arts, martial arts or self-defense. Furthermore, I understand that the risk of serious injury is present and I have been briefed on the relevant safety rules and regulations in place to help protect me and my fellow students during training.(required) Yes I have read the Assumption of Risk notice listed in the Students Menu on this website and I wish to participate within lessons, training sessions, gradings, and possibly competitions, provided by Close Combat Martial Arts and any registered instructors, coaches, or staff.(required) Yes I confirm that I have familiarised myself with the FAQ page, Club Charter, Club Rules, Club Principles, Club grades and Our Safeguarding Policy. and I have consulted with my Instructor if I don't under stand any of the information provided. (required) Yes I confirm that I understand the nature of the activity in which I am about to participate, and appreciate that any practice of combat, self-defense or martial art usually includes a degree of martial arts based fitness training. With this in mind, I can agree that I am fit to participate and agree to assume all risks associated with the above, hereby withdrawing any liability from the named club, instructors, association, or other relevant parties.(required) Yes I understand that if I fail to inform my instructor of any health issues that may later cause me problems, or fail to follow advice from my doctor, that I am fully liable for the consequences.(required) Yes Should I be unclear on any risks involved, or not feel comfortable releasing the above named from all positions of liability, I will not sign this document. Please take my signature as my acceptance and assumption of all risks involved, as described to me by my instructor and stated within this document.(required) Yes I fully understand the above statements and WILL NOT sign below if I don't. I have ticked each statement box as they are true. Please type your full name as a digital signature.(required) Send
