Medical form

If you are starting or renewing at London Savate, you need to fill in this medical and insurance form for our records.

Your Full Name*

Your Email*

Your Date of Birth*

Your address *

Your postcode*

Your Telephone*

Medical information*
- Do you currently take any prescribed medication?
- Do you have any special medical information or injuries that we should be aware of?
- If answering yes to either, please provide details (e.g. epilepsy, asthma, diabetes, etc.)

Martial arts and grades*
- Have you practised any form of Combat Sport or Martial Art before?
- If yes, what discipline was it, and what level did you reach?

Emergency contact info*
- In the unlikely event of an emergency, who would you like us to inform? (Please give a phone number).

I agree to the following:
- I agree to treat the safety of myself and others as paramount and to train responsibly.
- I agree to inform the instructor of any known personal health problems, conditions, injuries, and/or serious transmittable diseases (such as Hepatitis or HIV). This applies throughout my membership.

Data use: London Savate records may be kept on a computer for administration purposes only. This information is NOT made available to other organisations or agencies.

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