Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact Details *

First Name

Last Name

*

Phone

(###)

###

####

*

We consent for the club to use pictures and videos of me for club media, internet and literature.

We DO NOT consent for the club to use pictures and videos of me for the club media, internet and literature.

*

I agree to abide by the rules of Waverley Judo Club. I also declare that I will be respectful of others at all times and will participate in the true spirit of Judo.

For all students under 18 years *

I consent to my child taking part in the activities of Waverley Judo Club

Date Joined

MM

DD

YYYY