Kids Program Registration Form

Name *
Name
Phone *
Phone
Student Name *
Student Name
Student Birthdate *
Student Birthdate
Address *
Address
Please list any previous martial arts experience
How did you hear about our school?
Please list your reasons for wanting to try our program.
Are you currently under a Doctor’s care, on any medications, or have any previous injuries, illnesses or health concerns that would affect you in this class? If Yes, please explain:
Is there any other information you would like to share or questions that you have?
Select your program *
Please choose which of the following programs you would like to register for.
Acknowledgment and Acceptance of Risk and Responsibility: In consideration of being allowed to Participate in any way, the undersigned acknowledges, appreciates and agrees that: There are risks inherent in the nature of Martial Arts instruction and I understand that I will be voluntarily engaging in activities that involve the risk of serious injury, and am aware that strength, flexibility, Martial Arts and strenuous exercise is a potentially hazardous activity. I hereby agree to expressly assume and accept any and all risks of injury, and willingly agree to comply with the stated and customary terms and conditions for participation,. If I observe any unusual significant hazard during my participation, I will immediately advise the instructor of such condition(s), and/or remove myself from participation; and, I do hereby represent and warrant that I am physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in a Martial Arts/ Fitness program. I understand it is my responsibility to consult with a physician prior to and regarding all health related changes that may result from my exercise/ Martial Arts program. Release and Waiver of Liability: I voluntarily waive, release and discharge Robert Mesce, Martina Schmidt, Scholar Warrior Martial Arts, Inc, and its officers, employees, volunteers, representatives, contractors (“agents”) from any and all responsibilities or liability that are in any way connected with my participation in the practice of Martial Arts, including negligent acts or omissions of Scholar Warrior Martial Arts and its agents, for any and all injury or damage to myself. Further, I acknowledge that there may be other risks not known to me or not reasonably foreseeable at this time; and, I further agree and promise not to sue or assert any claim against Scholar Warrior Martial Arts and its agents for any injury, illness or damage to myself connected with my participation in the practice of Martial Arts or from any claim asserted against me by third parties; and, I agree to hold Scholar Warrior Martial Arts and its agents harmless and indemnify from all defense costs, attorney’s fees, or from any other costs incurred in connection with claims for bodily injury or property damage that I may negligently cause to third parties in the course of my participation in Martial Arts; and, I, the undersigned, being above age eighteen, do acknowledge and accept full responsibility for my participation in Martial Arts instruction in connection with Scholar Warrior Martial Arts and its agents. (If participant is under the age of eighteen, Parent’s or Guardian's signature required.) My signature indicates that I have read this entire document, understand it completely, and agree to be bound by its terms. I have read this acknowledgment and Acceptance of Risk and Responsibility, and Release and Waiver of Liability agreement, fully understand its terms, understand that I have given up substantial legal rights by signing it, and sign entirely of my own free will. I agree to participate knowing the risks and conditions involved and do so voluntarily.
Please check the box below *