LICENCE REGISTRATION

Licence Registration

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address Address Line 2 City ZIP / Postal Code

Email*

Enter Email Confirm Email

Occupation

Phone*

Grade*

Previous Licence Expiry Date

Only for New Applicants:

Have you ever practiced a martial art?

Yes

No

If yes, please give brief details including affiliation, grade obtained & examiner

Have you ever been convicted of a crime of violence?

Yes

No

If yes, please give brief details

Do you suffer a medical condition that could affect or prevent you practicing Karate?

Yes

No

If yes, please give details including any regular medication.

Upload Your Photo

Accepted file types: jpg, jpeg, png, gif.

All Registrations:

I accept that training in karate could involve the risk of injury’*

I accept

I don't accept

I also agree & acknowledge that my photograph may be taken during seminars and may be used by the Hombu Dojo & HDKI Ireland on Social Media or Brochures & related materials.*

I agree

I do Not agree

We will never identify you without your prior consent.

Select a Club*

Hombu Dojo New Licence / Renewal

For HOMBU DOJO CLUB members

HARTSTOWN SKC New Licence / Renewal

PALMERSTOWN SHOTOKAN New Licence / Renewal

ABBEYFEALE KARATE CLUB New Licence / Renewal

Renewal Arrears / Extra Years

Total

Credit Card

Card Details

Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.