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Mike's Ryukyu Kempo Karate & Kobudo™ Registration Form

Mike's Ryukyu Kempo Karate & Kobudo™ Registration Form

Must be at least 18 years old to complete this form. After you submit this registration, you'll see a "Thank You" screen where you can easily add another student. For assistance, contact our Dojo Head, Mike Tinsley, at (803) 646-0638 or email our Team at dojohall@hotmail.com.

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    Must be at least 6 years old or older to participate.
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    Select the Primary Contact's relationship with the student from the drop-down box below.
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    A "Mobile" Phone Number is our dojo's fastest and most preferred way to communicate with you. Please enter "Cell" as a first choice, followed by a "Cell Number" on the next screen. If no such device exists, select another choice from the drop-down box below.
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    Note: If applicable, you will be asked to provide an Emergency Number in a later section.
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    Select the Additional Contact's relationship to the student from the drop-down box below.
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  • 21
    A "Mobile" Phone Number is our dojo's fastest and most preferred way to communicate with the student’s Additional Contact. Please enter "Cell" as a first choice, followed by a "Cell Number" on the next screen. If no such device exists, select another choice from the drop-down box below.
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    Used in situations where we may need to contact you before your scheduled start date or visit for holidays, vacations, or emergency closings.
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    Verify or update if required. All invoices will be addressed and sent to this person.
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    Select ALL that applies.
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  • 28
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  • 29
    List all bone injuries, joint dislocations, and/or recent sprains from most recent to oldest.
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  • 30
    Ok, to estimate.
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  • 31
    You can list these handicaps in the next question under "Describe the enrolling student's health."
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  • 32
    Include any physical handicaps.
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  • 33
    These statements are necessary for our dojo to conduct business and cannot function properly without such provisions. Your acknowledgment and authorization are required for ALL SEVEN statements.
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  • 34
    Users with impairments may have trouble using a mouse to draw their initials or signature. Those users may choose to TYPE their initials and signature instead of drawing them.
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  • 35
    I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC INITIALS WILL BE AS VALID AS HANDWRITTEN INITIALS AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.
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  • 36
    I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC INITIALS WILL BE AS VALID AS HANDWRITTEN INITIALS AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.
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  • 37

     GENERAL WAIVER OF LIABILITY

    In consideration for my or my child's attendance and participation in the martial arts training offered by Mike’s Ryukyu Kempo Karate & Kobudo and the products sold by Mike’s Ryukyu Kempo Karate & Kobudo, I acknowledge the existence of certain inherent risks in this type of training and usage and hereby agree to assume all risks. I or any personal representatives further forever relieve Mike’s Ryukyu Kempo Karate & Kobudo, the school, its management, property owners, assigned staff, fellow participants, visitors, their families, or other representatives from liability resulting from bodily injury (partial and/or total disability), paralysis, viruses, any type of contagious sickness, death, or loss, whether personal belongings or bodily injury.

    I agree that my child or I will not attend any event at any time when my child or I believe that they might be ill, are experiencing any symptoms of illness, or have been exposed to a person or persons known to be infected with a contagious illness.

    I also hereby state that I or my child is physically fit to take the prescribed course of instruction and do so of my own free will.

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  • 38
    Must be at least 18 years old to answer.
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  • 39
    Do not include PERIODS (".") in the "Prefix" or "Suffix" fields if required.
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    I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC SIGNATURE WILL BE AS VALID AS A HANDWRITTEN SIGNATURE AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.
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  • 41
    I UNDERSTAND AND ACCEPT THAT MY ELECTRONIC SIGNATURE WILL BE AS VALID AS A HANDWRITTEN SIGNATURE AND CONSIDERED ORIGINAL TO THE EXTENT ALLOWED BY APPLICABLE LAW.
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    Type your email address below and select the "Send Verification Code ." Afterward, you will receive an email verification code from JotForm with "Email Verification Code Regarding Mikes Ryukyu Kempo Karate and Kobudo Registration Form" in the subject line. Follow the instructions provided.
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