Shaolin Temple Martial Arts and Cultural Centre - Taichi and Qigong for health - "AGE 60+" 
Email *
This fully funded project is for anyone age 65+ interested to improve overall health and wellbeing by gentle and calming Taichi and Qigong exercises
Please fill the form completely with the information of the participants, Incomplete forms will be rejected. (Different Email address for each participants as the form does not support duplicate email addresses)!
First Name *
Last Name *
Date of Birth (DOB) *
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Title *
Full Address *
Please include your postcode
Telephone *
NEXT OF KIN Full details (Full name, Address, Relationship) *
Health monitoring
Do you suffer from what have you ever suffered from, any of the following: (Please tick the appropriate)
Do you suffer from what have you ever suffered from, any of the following: (Please tick the appropriate) *
Required
Have you recently, or in the past 6 months had: (Please circle the appropriate) *
Required
Disability, learning difficulty and/or health problem. (Circle the appropriate) *
Required
Any Medical History (If non please write N/A) *
Medical Conditions (If non please write N/A) *
Ethnicity: *
Other Ethnicity:
I understand that participation in the above activities can be dangerous and that injury is possible. I will not hold the MAASIF, BCCMA the venue owners, the Shaolin Temple Martial arts and Cultural Centre, the governing body, the officials or other participants liable for any injuries received as a result of participating in the sport whether directly or indirectly received. As part of our Martial Arts activity, we occasionally use photography for publicity purposes by signing this form you permit Shaolin Temple Cultural Centre, to use photographs of you/your relative in our publications and publicity material, and for inclusion in the central STCC image library.
Please write your full name and date below, (This is your electronic signature for this document). If under 18 YRS old parent/ legal guardian must sign the form below.
Your details will be added to a central database our CRM system (coacha.co.uk) and you will be given access with login details to update your details (if online booking is needed), inform us of important changes and will be included in mailing list to be informed of the latest news and updates regarding the course.
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Full name of participant *
Date *
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Thank you for completing this form, We will contact you as soon as there is a place available and we have a start date for your group on either the phone number or the email you have provided above, to either grant you access to the course or ask for more information. 
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