Licence Application Form Welsh Judo Association Sport Wales National Centre Sophia Gardens, Cardiff, CF11 9SW Licence Category – Please tick appropriate category Category Annual 3 Month Trial
Senior s (16-34yrs) & Masters (35yrs+) £33 New £28 Renew £17 New Junior (8-15yrs) £24 New £19 Renew £15 New Dragon (5-7yrs) £17 New £12 Renew £11 New Annual Family Discount - £2 off each licence for three or more renewals at the same time from the same address. Fees non-refundable, cheques payable to – Welsh Judo Association Members Details
Title: First Names Surname
Date of Birth Licence Number: Parent Contact:
Address: Town:
County: Post Code:
Phone Number: Email Address:
Club Name: Club Number: Equality Information
Gender: Male Female Prefer not to say Heterosexual or Straight Gay or Lesbian Bisexual Sexuality: Unsure Other Prefer not to say White Welsh English Scottish Irish Gypsy Roma Traveller Ethnicity: Mixed / Multiple White & Black Caribbean White & Black African White & Asian
Black African Caribbean
Other Prefer not to say No Religion Buddhist Hindu Christian Jewish Muslim Sikh Religion: Other Prefer not to say Visually Hearing Physical Learning Multiple Long-Term No Disability Impaired Impaired Disability Disability Disability Illness Disability:
Other Prefer not to say Declaration I certify that to the best of my knowledge and belief, the information given in this application is correct. If accepted as a licence holder of the Welsh Judo Association, I agree to abide by the Articles of the Association and Bye-Laws together with any amendments made during the term of my licence and to comply with doping procedures. It is a criterion that all clubs, regions and affiliated bodies require staff, coaches, officials, administrators, parents and participants adopt and abide by the Welsh Judo Associations Child Protection Policy and Procedures, Equality Policy and Judo Code of Conduct. These documents are published on the WJA / BJA website. Hard copies can be obtained from the WJA / BJA Office. I consent to the information on this application being included on the WJA database. The Welsh Judo Association is registered under the terms of the Data Protection Act and wishes to include the information you have provided on this application on the WJA database for the purpose of administration and maintenance of membership records, provision and administration of activities, support and fundraising.
Members Signature Date:
Parent Signature (if under 16): Date:
I Wish to Receive Emails on: Membership Events Courses WJA Newsletter
[email protected] | 02920 334 945 | www.welshjudo.com