Polaris Dojo Sign Form

Polaris Dojo Membership
Parent/ Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
May we text or call you at this number?*

YesNo
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Participant*
(i.e. mother, father, uncle, friend, etc)

Student Name*

First NameLast Name
Birthday*

MonthDayYear
Would you like to add an additional student?*

YesNo
Student Name

First NameLast Name
Birthday

MonthDayYear
Student Name

First NameLast Name
Birthday

MonthDayYear
Student Name

First NameLast Name
Birthday

MonthDayYear
Student Name

First NameLast Name
Birthday

MonthDayYear
Student Name

First NameLast Name
Birthday

MonthDayYear
Student Name

First NameLast Name
Birthday

MonthDayYear

Liability Waiver
“I have enrolled in the personalized health and fitness program offered through Polaris Dojo. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in this exercise program. I acknowledge that my enrollment and subsequent participation is purely voluntary and in no way mandated by Polaris Dojo.

“In consideration of my participation in this program, I hereby release Polaris Dojo and its agents from any claims, demands, and causes of action as a result of my voluntary participation and enrollment.” “I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program and I hereby release Polaris Dojo and its agents from any liability now or in the future for conditions that I may obtain. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that I may incur, including death.”

I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS.
I agreeI do not agree

AUTOMATIC PAYMENT TERMS AND CONDITIONS

Note: All payment terms are subject to a 30-day written cancellation policy. Your cancellation of tuition payment terms will be dated from the day you complete a withdrawal form in our office. You are responsible for tuition for 30 days from date of written notice.

Scheduled Debit Terms: Signed authorization is to remain in full force and effect until the Polaris Dojo has received written notification of its termination in such time and manner as to afford Polaris Dojo a reasonable opportunity to act on it or until the term of authorization expires. Notice shall be completed in person at the HERC building or at Harbor School of Music & Dance.

Declined Payments Policy: All tuition installments are due on the 1st of the month and an attempt will be made to charge the account on file with the school at this time. Should any payments decline, a second attempt will be made on the account on file between the 2nd and 5th of the month. Should the card on file with the Polaris Dojo decline on the second attempt, an attempt to contact the account-holder will be made via phone, text or email as appropriate. Any payments made after the 10th of the month will incur a late fee of either $15.00 or 5% of the total due, whichever is greater.
I acknowledge and accept the Payment Terms and Conditions*

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Symptom Free Protocol
In order to reduce the spread of contagious illness, participants are prohibited from attending class while knowingly contagious.

Students may return to class:

-Once symptoms have begun to improve but no sooner than 36 hours after a fever of 99 degrees or higher.

-Or if cleared by a physician

-As soon as any course of treatment has been completed (i.e. for headlice or other non-viral contagion).

Students who are exhibiting symptoms of illness during class may be sent home at the intructor's discretion. No refunds due to illness will be offered except in exigent circumstances.
I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS*

I agreeI do not agree

Do you have any medical conditions that may affect your participation?

Media Release
I hereby agree and consent as follows.

A. I consent and authorize Polaris Dojo, located at PO Box 2889 Homer, AK 99603, to use my likeness in any photograph, video or other digital media (“Photos”) in any and all of its publications, including print or web-based publications.

B. I irrevocably authorize Polaris Dojo to copy, edit, enhance, crop, or otherwise alter any Photo for use in their publications. I also waive any rights for approval or inspection of any Photos.

C. I understand and agree that all Photos are the property of Polaris Dojo, and will not be returned to me.

D. I acknowledge that I am not entitled to any compensation or royalties with respect to the use of the Photos.

E. I agree to release and forever discharge Polaris Dojo and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them, in their individual and/or corporate capacities from any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any nature or kind, known or unknown, which I, and anyone claiming on behalf of me, may have or claim to have against Releasee in connection with this Release.

F. I have carefully read and fully understand all the provisions of this Photo Release Form and am freely, knowingly and voluntarily signing.
I agreeI do not agree

Please sign your acknowledgement.*

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Please Select which Program you are signing up for*

Cuong Nhu in HomerPrivate LessonsSingle Visit Complimentary Drop in
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