New Student Application

Today's Date*

Date

Student Name*

First NameLast Name

Student's Birth Date*

Age

Gender*

MALEFEMALE

Are you registering for a MUNIO Workshop.*

YESNO

Are you Registering for one of the Following*

Which class would the student like to attend?*

Nursery Ninja Karate (2-4 years old)

Which class would the student like to attend?*

Nursery Ninja Karate (2-4 years old)Lil Samurai Karate (4-8 years old)Ice Warrior Training (6+)

Which class would the student like to attend?*

Lil Samurai Karate (4-8 years old)

Which class would the student like to attend?*

Lil Samurai Karate (4-8 years old)Ice Warrior Training (6+)

Which class would the student like to attend?*

Lil Samurai Karate (4-8 years old)Zanshin Karate (8+years old)Kick Butt Kick Boxing (8+)Ice Warrior Training (6+)

Which class would the student like to attend?*

Zanshin Karate (8+years old)Kick Butt Kick Boxing (8+)Ice Warrior Training (6+)

Which class would the student like to attend?*

Zanshin Karate (8+years old)Kick Butt Kick Boxing (8+)Adult (Ages 13+)Ice Warrior Training (6+

dob-days

The student attends School . They are in Grade.

Parent/ Legal Guardian*

First NameLast Name

Parent/ Legal Guardian

First NameLast Name

Mobile Phone*

Please enter a valid phone number.

Personal Email*

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name*

First NameLast Name

Relationship*

Primary Phone*

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Contact Email

example@example.com

How did you hear about Zanshin Shotokan Karate*

Which friend told you about Zanshin Shotokan Karate?*

Are there any medical concerns we should be aware of that may effect exercise or focus?*

YesNo

If Yes Please explain your medical concerns:

Have YOU had previous Martial Arts or Kick Boxing Training?*

YesNo

If Yes What style, and what was your highest rank?*

Have any of your immediate family studied Martial Arts before?*

YesNo

What was/is their style and highest rank?*

Please select what you hope to accomplish with studying Shotokan Karate:*

Have you ever been put into a position where you have been threatened or attacked?*

YesNo

Are you concerned that you may be placed in a dangerous situation in the future?*

YesNo

Do you have children or are you responsible for children?*

YesNo

Have you ever been concerned for their safety?*

YesNo

Would you like to register for the next MUNIO self-defense workshop?*

YesNo, not this time.

Are you*

Law enforcementFirst responderActive militaryNone of the above

Ice Warrior Training - Current Team & Association*

Nursery Ninja Karate (2-4 yo)*

Lil Samurai Karate (4-8)*

KICK BUTT KICK BOXING*

Zanshin Karate (8+)*

Adult Karate (13+)*

Ice Warrior Training*

Did you find a class time that works for you?*

yes, I have selected a time and date.No, nothing fit with my/the student's schedule but I'm ready to start!

Please sign and date the waiver below after and press "submit":

Safety Release – I, the Member/guardian, fully recognize that there are dangers and risks to which Member may be exposed to by participating in the Marital Arts Class, which involves strenuous physical activity and extensive physical contact with other people including but not limited to punching, kicking and striking one another. Member/guardian understands and acknowledges that martial arts activities and the sport of karate in general have inherent dangers that no amount of care, caution, training, instruction, supervision or expertise can eliminate. With full understanding of the risks involved and despite this release, Member/guardian voluntarily enrolls in the Zanshin Shotokan Karate Club. Member/guardian therefore agrees to assume and take upon myself all of the risks and responsibilities in any way associated with this activity. Member/guardian releases Zanshin Shotokan, its agents, volunteers, and Robert Whatule from any and all liability, claims and actions that may arise from injury or harm to me, from my death or from damage to my property in connection with this tournament. I, Member/guardian, acknowledge and fully understand that I, Member/guardian, will be engaging in activities that involve risk of serious injury, and that severe social and economic losses may result not only from my own action, inactions or negligence, but also from the actions, inactions or negligence of other notwithstanding the rules of play or the condition of the premises or of any equipment used. Further I, Member/guardian, acknowledge and fully understand that there may be other associated risks with such activities that are not known or not reasonably foreseeable at this time. I understand that this Release covers liability, claims and actions caused entirely or in part by any acts or failures to act by Zanshin Shotokan, its agents, volunteers, including but not limited to negligence, mistake, or failure to supervise. I, Member/guardian, recognize that this Release means I am giving up, among other things, rights to sue Zanshin Shotokan Karate, its agents, and volunteers for injuries, damages, or losses Member/guardian may incur while participating in this class. I, Member/guardian, also understand that this release binds my heirs, executors, administrators, and assigns, as well as myself.

I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY OR DEATH, sustained while student participates in classes at the Zanshin Shotokan Karate , including the risk of PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, or hidden, latent or obvious defects in the facilities or equipment used.

Media Release – I, Member/guardian, give permission for images of Member, captured during regular and special activities through video, photo and digital to be used solely for the purposes of promotional material and publications, and waive any rights of compensation or Ownership thereto. I, Member/guardian, know the Member represents being physically fit to take the prescribed program. All use of the facilities shall be under taken at the sole risk of the Member/guardian.

I HEREBY FOREVER RELEASE, DISCHARGE AND COVENANT NOT TO SUE ZANSHIN SHOTOKAN KARATE. I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THIS DOCUMENT AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT. I HAVE READ THE ENTIRE RELEASE, I FULLY UNDERSTAND IT, AND I AGREE TO BE LEGALLY BOUND BY IT.

Signature*

New Student Application

Emergency Contact Info

Enjoy Your First Class Free!