Karate Student Enrollment Form (To fill after your free karate trial class)

Personal Info:

Student's Name(s):*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone #:*

Work Phone #:

Date of Birth (s):

MM slash DD slash YYYY

Medical Alert:

School:

Parent's Names:

Email:*

Do you have any previous martial arts experience?

Yes

If Yes, what style:

Do you have any current or past injuries our instructors should be aware of?

Yes

If Yes, What Injuries:

How did you hear of us?

To help assist us in reaching positive goals with your child please rate your child in the following areas.

Focus:

Low

Average

High

Balance:

Low

Average

High

Self Confidence:

Low

Average

High

Self Discipline:

Low

Average

High

Self Esteem:

Low

Average

High

Listening:

Low

Average

High

Fitness Level:

Low

Average

High

Emergency Contact Information:

Are there any problems or special considerations our instructors should be aware of?

Yes

Names:

Phone Number:

Cell Phone Number:

Participation/Activity Waiver of Liability

Participant Name*

First Name Last Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Email:

How did you find us?

Participation/ Activity Waiver of Liability*

I, the undersigned parent or guardian, hereby consent to my child participating in activities at NV Martial Arts Academy. I certify that my child is able to participate in activities at this location. In the event of emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached at the director in charge of the activity to make emergency medical decisions for my child.
I do hereby agree to hold NV Martial Arts Academy and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property which I not have or which may arise in the future connection with the activity or participation in any other associated activities.
I will follow all instruction given to me by NV Martial Arts and Fitness Academy and its teachers as to when, where, and how to perform during classes. I understand that any deviation by me from such instruction will be at my own risk.
I, my heirs or legal representatives, forever release, waive, discharge and covenant not to sue NV Martial Arts and Fitness Academy or its teachers for any injury or death caused by their negligence or other acts.
I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act.

I agree above

Signature of participant

Date

MM slash DD slash YYYY

If Participant is under the age of 18:*

First

Date

MM slash DD slash YYYY

Parent or Guardian Signature

Date

MM slash DD slash YYYY

Telephone number to reach in case of an emergency:*

PHOTO RELEASE FORM

Legal Guardian Name*

First

Terms and Conditions of Photo Publishing*

I hereby give permission for images of my child captured during Martial Arts class/events through video, photo, and digital camera to be used by NV Martial
Arts for the sole purposes of promotional martial and publications, including its website , fundraising, or any other like purposes. I further understand that by signing this release, I waive any and all present and future compensation rights to the above stated material.

I agree to the terms and conditions above.

Name of participant:*

First

Age:

Name of Parent/Guardian:*

First

Date

MM slash DD slash YYYY

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Please choose (check) the program(s) you are interested in enrolling in:**

Karate

Karate (ages 3-5)

Yoga

Tai Chi

Zumba

Kickboxing

Dance

Language

* The Customer promises and agrees to pay the following monthly or program fees by or on the first day of each month prior to receiving any instruction for that month or period and agrees to continue on the same for each consecutive month.
* Customer agrees that if payment is 5 days late an additional $10.00 will be added to monthly fee and an additional $10.00 every five days until payment is paid.
* Program(for martial arts students only) Circle One: Monthly 6-Month 12-Month

Program Start Date:

MM slash DD slash YYYY

Program End Month

(For martial arts students on 6 or 12 month program only):

MM slash DD slash YYYY

Members/Guardian Signature

Date:

MM slash DD slash YYYY

Consent*

(If under 18 years of age, this agreement must be signed by a parent or legal guardian)

I have read and understand this agreement & terms.*

Payment Method:

Name*

First

Drivers License Number:

Cash/Check:

If Card:*

Visa

Master Card

Account Number:

Exp Date:

MM slash DD slash YYYY

Sec.code:

Number of Payments:

Amount of Payment:

1st Due Date:

MM slash DD slash YYYY

Authorized Signature