Please fill in the following form to start your Free Two Week Trial Membership! Section A: Name* First Last GenderFemaleMaleDOB* Address* Street Address Address Line 2 City ZIP / Postal Code Phone*Email* Enter Email Confirm Email Is the person registering for a trial Over 18 years old?*YesNoSection B: Parent / Guardian ConsentFor all members 18 years and Under.Parent/Guardian First Last Entering your name here is an indication of your consent for the child named above in Section A to partake in trial classes with Hombu Dojo Karate.Other InformationIf you wish to supply us with any other information about your child e.g. any medical conditions, special needs, dietary requirementsIn case of a medical emergency:I AgreeIn the event of illness or accident, I give permission for medical treatment to be administered where considered necessary by a suitably qualified medical practitioner and/or hospital. I understand that every effort will be made to contact me as soon as possible. In an emergency I can be contacted at the telephone numbers supplied. I agree to allow the child named above to take part in Hombu Dojo Karate training and grading. I understand that there will be suitable supervision while the young people are in the care of the Hombu Dojo.Your relationship to the young person:ParentGuardianHave you any previous martial arts experience? if so please give brief details...Have you (person named in Section A) ever been convicted of a crime of violence? Yes No If yes, please give brief detailsDo you (person named in section A) suffer a medical condition that could affect or prevent you practicing Karate? Yes No If yes, please give details including any regular medication.I accept that training in karate could involve the risk of injury’* I accept Location I would like to start my Two Weeks Free TrialRanelaghBallyogan, Samuel Beckett Civic CampusChurchtown - De La SalleClonskeagh - David LloydHarold's Cross - YourFitness GymIrishtown StadiumNaas, Monread Community CentreRathmines - Swan LeisureSandyford Community CentreStillorgan, St BrigidsTallaght - Westpark GymTerenure Sports Clubplease note, all Adult classes only in Ranelagh or NaasPlease send me more details about membership fees and joining your clubyes pleaseI have already read it on this site thanksNameThis field is for validation purposes and should be left unchanged.