146 lines
7.5 KiB
HTML
146 lines
7.5 KiB
HTML
<html lang="en"><head>
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<meta http-equiv="content-type" content="text/html; charset=UTF-8">
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<title>Pa-Kua Cambridge Student Registration Form</title>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width,initial-scale=1,minimum-scale=1">
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<meta name="author" content="Pa-Kua Cambridge">
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<link rel="stylesheet" href="style.css" media="all" />
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<link rel="stylesheet" href="print.css" media="print">
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</head>
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<body>
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<div id="logo"><img src="pakua-logo-greyscale.svg" alt="logo of the Pa-Kua International League"></div>
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<h1 id="pa-kua-cambridge-safeguarding-policy--statement">Pa-Kua Cambridge Student Registration Form</h1>
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<form>
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<fieldset>
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<label for="regform_name">Student's printed name </label>
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<input name="regform_name" id="regform_name" type="text">
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<label for="regform_dob">Student's date of birth</label>
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<span class="inputdate">
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<input name="regform_dob_day" id="regform_dob_day" type="text" placeholder="DD" class="date">/
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<input name="regform_dob_month" id="regform_dob_month" type="text" placeholder="MM" class="month">/
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<input name="regform_dob_year" id="regform_dob_year" type="text" placeholder="YYYY" class="year">
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</span>
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</fieldset>
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<fieldset>
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<label for="regform_addr">First line of address</label>
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<input name="regform_addr" id="regform_addr" type="text">
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<label for="regform_city">City</label>
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<input name="regform_city" id="regform_city" type="text">
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<label for="regform_postcode">Postcode</label>
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<input name="regform_postcode" id="regform_postcode" type="text">
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</fieldset>
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<fieldset>
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<label for="regform_phone">Phone number</label>
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<input name="regform_phone" id="regform_phone" type="text">
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<label for="regform_email">E-mail address</label>
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<input name="regform_email" id="regform_email" type="email">
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</fieldset>
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<fieldset>
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<legend>Emergency contact</legend>
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<label for="regform_emergency">Name</label>
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<input name="regform_emergency" id="regform_emergency" type="text">
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<label for="regform_emergency_relationship">Relationship to student</label>
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<input name="regform_emergency_relationship" id="regform_emergency_relationship" type="text">
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<label for="regform_emergency_phone">Phone</label>
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<input name="regform_emergency_phone" id="regform_emergency_phone" type="text">
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</fieldset>
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<fieldset>
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<legend>For students under the age of 18</legend>
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<label for="regform_parent">Parent/guardian name</label>
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<input name="regform_parent" id="regform_parent" type="text">
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<fieldset>
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<legend>People allowed to pick up your children</legend>
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<div>
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<label for="regform_collector1">Name</label>
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<input name="regform_collector1" id="regform_collector1" type="text">
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<label for="regform_collector1_relationship">Relationship</label>
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<input name="regform_collector1_relationship" id="regform_collector1_relationship" type="text">
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<label for="regform_collector1_phone">Phone</label>
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<input name="regform_collector1_phone" id="regform_collector1_phone" type="text">
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</div>
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<div>
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<label for="regform_collector2">Name</label>
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<input name="regform_collector2" id="regform_collector2" type="text">
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<label for="regform_collector2_relationship">Relationship</label>
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<input name="regform_collector2_relationship" id="regform_collector2_relationship" type="text">
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<label for="regform_collector2_phone">Phone</label>
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<input name="regform_collector2_phone" id="regform_collector2_phone" type="text">
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</div>
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</fieldset>
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</fieldset>
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<div class="pagebreak"></div>
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<fieldset>
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<label class="wide" for="regform_medical">History of injuries or medical information relevant to the practice</label>
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<textarea name="regform_medical" id="regform_medical"></textarea>
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</fieldset>
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<fieldset>
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<legend>Acknowledgement and Assumption of Risks</legend>
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<p>
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I am completing this assumption of risk form in relation to my wishes to participate within a class, activity, course, seminar, grading, competition, training session or lesson provided by Pa-Kua Cambridge and any of the clubs of the Pa-Kua International League registered instructors, coaches, Masters, or staff.
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</p>
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<p>
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I confirm that I understand in full that any activity in which I participate will carry inherent risks associated with any practice or competition within combat arts, martial arts or self defence. Furthermore, I understand that the risk of serious injury is present and I have been briefed on the relevant safety rules and regulations in place to help protect me and my fellow students during training.
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</p>
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<p>
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I confirm that I understand the nature of the activity in which I am about to participate, and appreciate that any practice of combat, self defence or martial art usually includes a degree of martial arts based fitness training. With this in mind, I can agree that I am fit to participate and agree to assume all risks associated with the above, hereby withdrawing any liability from the named club, instructors, association or other relevant parties.
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</p>
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<p>
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Should I be unclear on any risks involved, or not feel comfortable releasing the above named from all positions of liability, I will not sign this document. Please take my signature as my acceptance and assumption of all risks involved, as described to me by my instructor and stated within this document.
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</p>
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<p>
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The club should retain this document for future reference. If the named wishes to obtain a copy, the instructor must make this available within 21 days without charge.
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</p>
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</fieldset>
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<fieldset>
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<div>
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<label for="regform_student_signature">Student's (or Guardian's) Signature</label>
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<input name="regform_student_signature" id="regform_student_signature" type="text">
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</div>
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<div>
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<label for="regform_instructor_name">Instructor's Printed Name</label>
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<input name="regform_instructor_name" id="regform_instructor_name" type="text">
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<label for="regform_instructor_signature">Instructor's Signature</label>
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<input name="regform_instructor_signature" id="regform_instructor_signature" type="text">
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<label for="regform_date">Date</label>
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<span class="inputdate">
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<input name="regform_dob_day" id="regform_dob_day" type="text" placeholder="DD" class="date">/
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<input name="regform_dob_month" id="regform_dob_month" type="text" placeholder="MM" class="month">/
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<input name="regform_dob_year" id="regform_dob_year" type="text" placeholder="YYYY" class="year">
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</span>
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</div>
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</fieldset>
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</form>
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</body>
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</html>
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