令和5年度第3期 水中歩行教室 申込書.pdf

Please mark your preferred class with ○.
Monday course (13:00-), AQ venue, 4,000 yen
Wednesday course (13:00-), AQ venue, 4,000 yen
Friday course (13:00-), AQ venue, 4,000 yen
Please fill in the corresponding box with ○.
Continuation, past participation, new participation
Furigana, applicant's name, gender (age)
Male, female, age () years old
Phone number, home (), daytime ()
Email address
Sports safety insurance, please mark the corresponding box with ○.
Will you join the sports safety insurance for the 5th year of Reiwa?
(1,850 yen for 64 years old and under, 1,200 yen for 65 years old and over)
() Joined, () not joined, () will join
Current health status, please mark the corresponding box with ○.
() Good, () hypertension, () diabetes, () arrhythmia
() Heart disease, () other ""
【From here, only "new participants" and "those who have participated in the past" should fill in】
Continuers who have changed their address should only fill in "home address"
Home address
Experience participating in our foundation's classes () yes (class name), () no (class name)
Questions
Have you ever been in a pool? () yes () no
Can you put your face in the water? () yes () no
Are you over 145cm tall? () yes () no
Remarks: If you have any health conditions or other special notes, please fill them in.
NO.
Receipt stamp
¥4,000
Public Interest Incorporated Foundation Kashiwazaki Shinko Foundation
1. This application form will not be used for any other purpose.
2. No refunds can be made after payment.
*3. Due to water depth, only those over 145cm tall are eligible.