Martial Arts Course Registration Form

Athlete Information

Athlete's Name

First NameLast Name

Birth date

DayMonthYear

Gender

MaleFemaleOther

Style

Adult & teen Kung fuTai chi & Qi gongKids Kung fuOther

Date

Parent/Guardian Information (if athlete is under 18)

Name

First NameLast Name

Mobile Number

eg 021Phone Number

E-mail

example@example.com

Alternative Emergency Contact

Emergency Contact's Name

First NameLast Name

Mobile Number

eg 021Phone Number

Does the athlete have asthma, allergies, or any other medical condition? If yes, please describe.

Membership

Membership type

Monthly Payment3 Months Sign upPrivate Classes

Payment option

Cash - please make payment at beginning of class on your due dateOnline payment - use online PayPal button on your due date

Acknowledgement I understand that all sports carry a risk of injury and that Freedom Kung fu is not responsible for injuries or loss suffered as the result of participating in these activities. Freedom Kung fu will give 30 days written notice of any fee increase.

Medical Authorization In the event of an injury or medical emergency, I allow Freedom Kung fu to provide first aid, arrange transport to a medical facility, and authorise emergency treatment as recommended by a doctor for the athlete named above. I understand that all reasonable efforts will be made to contact the athlete’s parent and/or emergency contact if an injury or medical emergency occurs.

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.

Signature of Participant, Parent, or Legal Guardian