Free Class Detailed Registration Form w consent

Registration Includes

Uniform FREE included with your registration!!!

Student Information

Athlete's Name*

First NameLast Name

Birth Date*

MonthDayYear

Age Group*

Gender*

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Additional Students

Parent/Guardian Information

Parent Name

Cell Number

Area CodePhone Number

E-mail

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Dearie Karate Studio & Lima Lama DKS during the selected class. In exchange for the acceptance of said child’s participation by Dearie Karate Studio & Lima Lama DKS ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Dearie Karate Studio & Lima Lama DKS . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected class sessions.

In case of injury to said child, I hereby waive all claims against Dearie Karate Studio & Lima Lama DKS . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including karate. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic Signature:*

I have read and agree to the Informed Consent and Acknowledgement.

Sign Here

Date*

MonthDayYear

Dearie Karate Studio Registration