Student name * First Name Last Name DOB. MM DD YYYY Medical Questionare If your answer is 'yes' to any of the following questions please check the box. History of heart problem, chest pain or stroke? High Blood pressure? Any chronic illness or condition? Recent surgery in the pass 12 months? History of breathing or lung problems? Muscle, joint or back disorder, or any previous injury still affecting you? Diabetes or thyroid conditioning? Parent Guardian * First Name Last Name Phone * (###) ### #### Email Address * City / Town * Postcode * Terms & Conditions I understand that whilst every care will be taken to give safe instruction, I accept full responsibility for any injuries incurred whilst training at MNBJJ Glasgow and consider myself fit to exercise. I have answered all questions correctly and all medical and health considerations are noted above. *Please note it is the student or parent/guardian responsibility to inform the instructor of any medical condition that may affect your health whilst under their instruction as the information declared on this form is not passed on to anyone. * I Agree to the above Terms & Conditions Direct Debit Bank Details: Direct Debit Details Full membership unlimited classes £40 Monthly. We will be collecting your membership fee via Direct Debt on the first of every month. Cancellation of Membership: You must give MNBJJ 2 weeks notice to cancel your membership and stop your direct debt. Name First Name Last Name 8 Digits Account Number: * 6 Digits Sort Code: * Concent * I agree to the monthly DD Date MM DD YYYY Thanks for Joining the MNBJJ Glasgow team.We look forward to seeing you in class.
