Martial Arts School - Taining Rising Dragon

School Application Form

Please Note - We are currently experiencing problems with the application process. If we do not contact you within 1 day then please email the school direct or fill your details on the Contact Page.

This application should be completed as fully as possible. The information will be treated
in confidence by the Rising Dragon Health Adviser.

By completing this form you are agreeing to the rules and way of living of the Rising Dragon Martial Arts School.
If you are accepted you will receive an email within 7 days containing a link directing you to Pay-pal where you will pay your Reservation fee of $150.

PLEASE COMPLETE IN CAPITAL LETTERS

Required input *

First name:

Middle name:

Family name:

Date of birth:

Gender

Female
Male

Nationality:

Marital status:

Occupation:

Email address:

Contact telephone number:

Current home address:

Current location:

What date would you like to attend our School?

from:

click on field for calendar

How long would you like to stay at our School?

until:

click on field for calendar

What style would you like to study?

Previous Martial Arts studied & for how long?

Extra information you feel is relevant:

Medical Questionaire

1.	What is your weight:	*	lbs
2.	What is your height:	*	ft ins
3.	Are you currently receiving any form of medical supervision or taking prescribed medication: (e.g. attending physiotherapy, osteopath, hospital outpatients, taking regular medicine)
	If the answer to question 3 is YES: please give details.

4.	When did you last consult your GP and why:			click on field for calendar
	Question 4. Please give details
Are you currently suffering from or have suffered from any of the illnesses listed below:-
5.	Heart trouble		YES NO
	If the answer to question 5 is YES: please give details.
6.	Lung disease (eg TB, Bronchitis)		YES NO
	If the answer to question 6 is YES: please give details.
7.	Stomach / Bowel trouble		YES NO
	If the answer to question 7 is YES: please give details.
8.	Jaundice / Hepatitis / HIV		YES NO
	If the answer to question 8 is YES: please give details.
9.	ME/Post Viral fatigue syndrome		YES NO
	If the answer to question 9 is YES: please give details.
10.	Joint problems		YES NO
	If the answer to question 10 is YES: please give details.
11.	Diabetes		YES NO
	If the answer to question 11 is YES: please give details.
12.	Epilepsy		YES NO
	If the answer to question 12 is YES: please give details.
13.	Any allergies (beg Hay fever, eczema etc)		YES NO
	If the answer to question 13 is YES: please give details.
14.	Frequent / severe headaches or migraine		YES NO
	If the answer to question14 is YES: please give details.
15.	Ear problems		YES NO
	If the answer to question 15 is YES: please give details.
16.	Hearing problems		YES NO
	If the answer to question 16 is YES: please give details.
17.	Severe Stress Reaction		YES NO
	If the answer to question 17 is YES: please give details.
18.	High blood pressure		YES NO
	If the answer to question 18 is YES: please give details.
19.	Asthma		YES NO
	If the answer to question 19 is YES: please give details.
20.	Hernia or rupture		YES NO
	If the answer to question 20 is YES: please give details.
21.	Kidney or bladder disorders		YES NO
	If the answer to question 21 is YES: please give details.
22.	Back / neck problems		YES NO
	If the answer to question 22 is YES: please give details.
23.	Fits / faints / blackouts /		YES NO
	If the answer to question 23 is YES: please give details.
24.	Depression / anxiety / other		YES NO
	If the answer to question 24 is YES: please give details.
25.	Mental health problem		YES NO
	If the answer to question 25 is YES: please give details.
26.	Surgical operations		YES NO
	If the answer to question 26 is YES: please give details.
27.	Eye problems		YES NO
	If the answer to question 27 is YES: please give details.
28.	Sight problems		YES NO
	If the answer to question 28 is YES: please give details.

29.	How did you hear about our School?
Declaration

I hereby declare that the information given is full and trust to the best of my knowledge. I understand that if, at a later date, it is discovered that I have knowingly withheld medical information, the Rising Dragon Martial Arts School may take disciplinary action against me, which may include dismissal from the school.

Signature: Please insert your name in full
Date		click on field for calendar

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