British Judo Association, Suite B,
Loughborough Technology Centre,
Epinal Way, Loughborough, Le11 3Ge
Tel: 01509 631670 • Fax: 01509 631680
e-mail: [email protected]
www.britishjudo.org.uk
MEMBERSHIP APPLICATION: PLEASE COMPLETE IN BLOCK CAPITALS AND SIGN OVER THE PAGE.
Address
Postcode
Contact number
E-mail Address
Club Name
Club Number
County you wish to represent
Player 1
Surname
First Name(s)
Date of Birth
Disability
Ethnic Group
(see over page for code)
(see over page for code)
Licence Number
Expiry Date
(if renewal)
(if renewal)
Player 2
Male
Female
Two years
4 Months
Date of Birth
Disability
Ethnic Group
(see over page for code)
(see over page for code)
Term of
Membership
(Tick One)
Expiry Date
(if renewal)
(if renewal)
Male
Female
Senior
Renewal
Student/Youth
Status of
Membership
(Tick One)
Two years
4 Months
Date of Birth
Disability
Ethnic Group
(see over page for code)
(see over page for code)
Expiry Date
(if renewal)
(if renewal)
Surname
Male
Female
Senior
Student/Youth
4 Months
Disability
Ethnic Group
(see over page for code)
(see over page for code)
Expiry Date
(if renewal)
(if renewal)
Male
Female
Price
(see
opposite)
Junior
Senior
Renewal
Student/Youth
Price
(see
opposite)
Recreational
Status of
Membership
(Tick One)
One year
Licence Number
Category of
Membership
(Tick One)
New
First Name(s)
Date of Birth
Junior
Renewal
Status of
Membership
(Tick One)
Two years
Term of
Membership
(Tick One)
(see
opposite)
Recreational
One year
Licence Number
Category of
Membership
(Tick One)
New
First Name(s)
Term of
Membership
(Tick One)
Junior
Price
Recreational
One year
Licence Number
Category of
Membership
(Tick One)
New
First Name(s)
Surname
Player 3
Status of
Membership
(Tick One)
One year
Surname
Player 4
Term of
Membership
(Tick One)
Two years
4 Months
Category of
Membership
(Tick One)
Junior
New
Senior
Renewal
Student/Youth
Recreational
DEDUCT FAMILY DISCOUNT: (Not available for pay as you throw renewals)
£5 For second and each subsequent family member (same household on same form only)
–
If Surnames Differ, please State Family Connection
BJA Record Book may be purchased with a Recreational Licence (Provided free with all other new licences)
+ £2.50 each
BJA branded plastic licence holder. Also specify W for White and S for Silver.
+ £2.99 each
Novice to 6th Mon Judo Diary (Provided free with Junior New Membership)
+ £5.00 each
7th to 12th Mon Judo Diary (Provided free when passing 6th Mon)
+ £5.00 each
13th to 18th Mon Judo Diary (Provided free when passing 12th Mon)
+ £5.00 each
Novice to 1st Kyu Judo Diary (Provided free with senior and student / youth new membership)
+ £5.00 each
Add Donation to the British Judo Trust
TOTAL AMOUNT PAYABLE
Please now complete the declaration and payment details on next page
+
Price
(see
opposite)
British Judo Association, Suite B,
Loughborough Technology Centre,
Epinal Way, Loughborough, Le11 3Ge
Tel: 01509 631670 • Fax: 01509 631680
e-mail: [email protected]
www.britishjudo.org.uk
MEMBERSHIP APPLICATION cont. - PLEASE COMPLETE IN BLOCK CAPITALS
DECLARATION
I certify that to the best of my knowledge and belief, the information given in this application is correct. If accepted as a member of the British Judo
Association, I agree to abide by the Articles of Association and Byelaws together with any amendments made during the term of my membership and
to comply with doping control procedures.
It is a criterion that all clubs, regions and affiliated bodies require staff, coaches, officials, administrators, parents and participant to adopt and abide
by the British Judo’s Safeguarding Policy and Procedures, Equality Policy and Judo Code. These documents are published on the BJA web site.
Hard copies can be obtained from BJA Head Office. Breaches of the Judo Code and other relevant codes of conduct/ethics will result in disciplinary
action being taken under the BJA Complaints & Conduct Procedures.
The British 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 BJA database for the purpose of administration and maintenance of membership records, provision and administration of activities,
support and fund raising. Please complete the following section to indicate your consent to this process.
I consent to the information on this application being included on the BJA database and agree to abide by the declaration above.
Signed
Date
Applicant if over 18 years / Parent or Guardian if under 18 years
If Parent or Guardian print name
Relationship to Applicant
Enclose payment with completed application form and forward to the British Judo Association, Suite B, Loughborough Technology Centre, Epinal way,
Loughborough, LE11 3GE. Cheques and postal orders payable to British Judo Association. Please write licence number and/or post code on back of cheque.
Credit / Debit Card Number
Issue Date (if available)
Issue Number (Switch Users Only)
Card Expiry Date
CVC ( Security) number
Signed
Date
ETHNIC GROUP - Please choose the category that best describes your ethnic group from the following list.
Enter the code (and write in other description where appropriate) on your application.
White
A1. British
A2. Irish
A3. Any other White group (please write in)
Mixed or Mixed British
B1. White &
Black Caribbean
B2. White &
Black African
B3. White and Asian
B4. Any other Mixed group (Please write in)
Asian or Asian British
C1. Indian
C2. Pakistani
C3. Bangladeshi
C4. Any other Asian group (please write in)
Black or Black British
D1. Caribbean
D2. African
D3. Any other Black group (please write in)
Chinese or other ethnic group
E1. Chinese
E2. Any Other group (please write in)
Providing this information is optional but helps British Judo monitor the participation levels of under-represented groups. We use the data to
research barriers and issues that these groups may face when accessing our sport.
DISABILITY
The Disability Discrimination Act 1995 defines a disabled person as anyone with a “physical or mental impairment that has a substantial and
long term adverse effect upon his/her ability to carry out normal day to day activities”. If you consider yourself to have a disability, please
choose the description that best describes the nature of your disability and enter the code (and write in other description where appropriate)
on your application.
A. Visually Impaired
B. Hearing Impaired
C. Physical Disability
D. Learning Disability
E. Multiple Disability
F. Other (please write in)
Need a judogi?
Why not visit British Judo’s official merchandise website:
www.judostore.co.uk