Ilyo Taekwondo Club
Old Borough National School, Church Road, Swords, Co.Dublin.
Tel: 086 037 7587. E: ilyotaekwondoclub@gmail.com

                                    Membership Form

PLEASE COPY, PASTE TO WORD AND PRINT. COMPLETE THE FORM AND RETURN BY POST WITH YOUR PAYMENT TO: Paul Sheridan, Ilyo Taekwondo Club, Old Borough National School, Church Road, Swords, Co.Dublin. Cheques payable to Ilyo Taekwondo Club.

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Licence/Membership Application Form 2012

Please complete in BLOCK CAPITAL

Name......................................................................................................................................

Address....................................................................................................................................

................................................................................................................................................

Home Telephone ..................................................... Mobile………………………………………………….

Parent/Guardian’s Email………………….........................................................................................

Date of Birth ……....../................/.............. Age……………………………………….....................

Grade…………………........................................... Male/Female……………………………………………..

Membership Number (in licence book) ....................................................................................

Have you any Special Needs, Disability, Injuries/Weakness or Illness? YES............... NO.............

Please supply summary, but inform your instructor of all details if there is medication required in regarding to Allergies/Diabetics etc...................................................................................................................................................

..................................................................................................................................................

WTF TAEKWONDO IS A FULL CONTACT SPORT AND THERE IS A RISK OF INJURY

I acknowledge that I have been informed of the nature and potential risks of practising Taekwondo. I apply for membership to the ITU and agree to comply with the rules and regulations of the board.

Signed................................................................................. Date.........../........../2012

To be completed by the parent or guardian for all applicants under 18 years of age:

I acknowledge that I have been informed of the nature and potential risks of practising Taekwondo. I agree to my son/daughter applying for membership to the ITU.

Signed…………………............................................................ Date....…../...……./2012

Club Name: Ilyo Taekwondo Club ……………………………………………………………………………………………………….

Instructors Name: Paul Sheridan…………………………………………………………

Instructors Contact No.: 0860377587…………………………………………………………………………………

ITU Licence & Insurance Fee: 20.00 Euro

Signed:……Paul Sheridan Chief Instructor………………………………………

For official use only

Number………………………………………………….. Expires …………../…………………/……………