Date of joining (today’s date)

Club name:

Senior Instructor name:

Website:

Club email

Club dojang locations:

Instructor’ names AND ranks: (Should you have a very large list please upload/copy your list here (ensure you include your Club Name and the heading Instructors at the top of your list))

Black Belts names and ranks: (other than those already listed as instructors): Should you have a very large list please upload/copy your list here (ensure you include your Club Name and the heading BLACK BELTS at the top of your list)

Total colour belt students (number only):