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Student Information 2017-08-29T11:11:11+00:00

First Name*

Middle Initial*

Last Name*

Date of Birth* (xx/xx/xxxx)*


Phone Number*







1st Parent First Name

1st Parent Last Name

Mailing Address

City / State / Zip

Phone

Email

You represent that you (the student) have no emotional, mental or physical illness that could impair training or make the training injurious. While every effort will be made on our part to make the classes and facilities as safe as possible, you realize that any physical activity has the potential for injury and you waive any claim of accidental and/or negligent tort damage against us and/or our principal officers or instructors resulting from the activity. I hereby acknowledge an assumption of risk by accepting and agreeing to allow my child/myself to participate in martial arts and/or other related activities including karate camps & field trips.

I Accept | By clicking "I Accept", you confirm you have read and understand the waiver and the information you provided electronically is true to the best of your knowledge. You also agree to submit this form with your signature, electronically.

Student e-Signature*