Student Application - Encinitas Karate

First Name *

Last Name *

Age *

Parent's Name/s (If student is a minor)

Address *

Address

City

State/Province

Zip/Postal

Student / Occupation *

Email *

Name of School Attended

For 18 Yrs. and Younger

Cell Phone *

Alternative Phone

What Benefits Are You Most Interested In Obtaining By Participating/Training In Our Program?

How Did You Hear About Us? *

Any Previous Martial Arts Training? *

Yes

No

Style: *

Rank: *

Where Studied: *

Health Condition:

Please list any physical defects, illnesses or conditions (such as asthma, epilepsy, high blood pressure, ADD, ADHD, autism, etc.

I agree there are NO physical conditions or illnesses which would render the applicant unable to participate in a strenuous physical activity, such as martial arts training.

Physical Condition Agreement & Acknowledgment *

Recognizing that the nature of this activity involves risk of personal injury, and with this knowledge, the applicant agrees to indemnify and hold harmless Encinitas Karate, Inc. and it's officers, instructors and staff from any and all liability and losses whatsoever arising from participation in this program.

Risk of Personal Injury Waiver *

I hereby enroll myself/my child for Tang Soo Do and self-defense training in a: *

$39 Introductory Course

OtherOther

Student Signature *

Clear

Date *

Guardian Signature *

Clear

Date *