She Kicks Intro Registration Form

She Kicks Karate Registration

Be Ready. Be Powerful. Be Your Best
Today's Date

MonthDayYear
Date
Athlete Information
Athlete's Name

First NameLast Name
Birth date

DayMonthYear
MaleFemaleOther
YesNo
Parent/Guardian Information (if athlete is under 18)
Name

First NameLast Name
Mobile Number

Area CodePhone Number
E-mail
example@example.com
Alternative Emergency Contact
Emergency Contact's Name

First NameLast Name
Mobile Number

Area CodePhone Number
Does the athlete have asthma, allergies, or any other medical condition? If yes, please describe.
Membership
Introductory offer: 2 classes for $19.95
Location

She Kicks Karate classes are currently located on the campus of Zion Institute.

1522 E. Southern Avenue, Phoenix, AZ 85040.

Classes are Mondays and Wednesdays at 6pm and Saturdays at 11:00am.
Acknowledgement

I understand that all sports carry a risk of injury and that She Kicks Karate is not responsible for injuries or loss suffered as the result of participating in these activities.

From time to time She Kicks Karate will post photographs of our athletes, coaches, and supporters online. I will let She Kicks Karate know by email if I do not consent to my or my child’s photos being shared.

She Kicks Karate will give 30 days written notice of any fee increase.
Medical Authorization

In the event of an injury or medical emergency, I allow She Kicks Karate to provide first aid, arrange transport to a medical facility, and authorize 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.

My Products

Introductory offer$19.95

Quantity

Total $0.00

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She Kicks Karate Registration

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