Karate for Christ Registration

Karate for Christ/Heiwa Karate-Do Registration

Sensei Deo Namwira, 5th Dan - International Meibukan Gojyu-Ryu Karate-do Association - BN 8071 951 - de4j@yahoo.ca - www.heiwakaratedo.com
Name*

First NameLast Name
I am registering*

myself (18 years or older)my child (under 18 years old)myself & children under 18
Participant Date of Birth

MonthDayYear
Date
Child Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Registering more than one child:

YesNo
Child 2 Name

First NameLast Name
Child 2 Date of Birth

MonthDayYear
Date
Child 3 Name

First NameLast Name
Child 3 Date of Birth

MonthDayYear
Date
Child 4 Name

First NameLast Name
Child 4 Date of Birth

MonthDayYear
Date
Participant Medical Issues
Previous Martial Arts Experience of Participant(s)
Please include style and rank achieved
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com

Waiver Under 18

I hereby make application of my child(ren) for full membership in the Meibukan Goju Karate Heiwa Dojo and, upon acceptance; We sincerely pledge to obey all Dojo rules and regulations that were formulated for the purpose of keeping order in the Dojo and for the protection of pupils from injury. I further acknowledge and understand that a risk of injury is involved requiring our strict adherence to these rules and regulations, and to the Instructor(s) discipline.

In consideration of accepting my application, I, my heirs, executors and administrators do hereby forever release, remise and discharge the International Meibukan Goju-ryu Karate-do Association (IMGKA), it’s board, staff, members and associates; and the Meibukan Gojyu Karate Heiwa Dojo, its instructors, members and authorized guests from all responsibilities and all claims for injury which I may receive while practicing the art of Meibukan Gojyu-ryu Karate-do. The parents or guardians of the applicant hereby request that this application be accepted and, in consideration of this acceptance, hereby agree to indemnify the International Meibukan Goju-ryu Karate-do Association, it’s board, staff, members and associates; and Meibukan Gojyu Karate Heiwa Dojo, its instructors, members and authorized guests, of and from all manner of claims made by or on behalf of the applicant.

I have read and understood all of the aforementioned rules and regulations and sincerely pledge to adhere to them and to the instructor’s discipline.

Photos & Video

I understand than my childs likeness, with or without a caption, may be published by Heiwa Karate-do or IMGKA without surname or personal information.
I grant permission for the Meibukan Goju Karate Heiwa Dojo and/or IMGKA publishing as described above.

Medical Emergency

In case of medical emergency, parent/guardian gives consent for MEDICAL TREATMENT to be given to participant by CERTIFIED MEDICAL PROFESSIONALS or by qualified first aide staff. I also give permission for my child to be transported by ambulance or car to an emergency center for treatment. I understand that accident or health insurance is the responsibility of parents or legal guardians.

Communication

I consent to regular information emails being delivered to the address provided. I understand that I may unscubscribe at any time.
Waiver Adult

I hereby make application for full membership in the Meibukan Goju Karate Heiwa Dojo and, upon acceptance; I sincerely pledge to obey all Dojo rules and regulations that were formulated for the purpose of keeping order in the Dojo and for the protection of pupils from injury. I further acknowledge and understand that a risk of injury is involved requiring our strict adherence to these rules and regulations, and to the Instructor(s) discipline.

In consideration of accepting my application, I, my heirs, executors and administrators do hereby forever release, remise and discharge the International Meibukan Goju-ryu Karate-do Association (IMGKA), it’s board, staff, members and associates; and the Meibukan Gojyu Karate Heiwa Dojo, its instructors, members and authorized guests from all responsibilities and all claims for injury which I may receive while practicing the art of Meibukan Gojyu-ryu Karate-do. The parents or guardians of the applicant hereby request that this application be accepted and, in consideration of this acceptance, hereby agree to indemnify the International Meibukan Goju-ryu Karate-do Association, it’s board, staff, members and associates; and Meibukan Gojyu Karate Heiwa Dojo, its instructors, members and authorized guests, of and from all manner of claims made by or on behalf of the applicant.

I have read and understood all of the aforementioned rules and regulations and sincerely pledge to adhere to them and to the instructor’s discipline.

Photos & Video

I understand than my likeness, with or without a caption, may be published by Heiwa Karate-do or IMGKA without surname or personal information.
I grant permission for the Meibukan Goju Karate Heiwa Dojo and/or IMGKA publishing as described above.

Medical Emergency

In case of medical emergency, I give consent for MEDICAL TREATMENT to be given to participant by CERTIFIED MEDICAL PROFESSIONALS or by qualified first aide staff. I also give permission to be transported by ambulance or car to an emergency center for treatment. I understand that accident or health insurance is the responsiblity of the participant.

Communication

I consent to regular information emails being delivered to the address provided. I understand that I may unscubscribe at any time.
Date*

MonthDayYear
Date
I agree to the terms above - Signature*

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Please verify that you are human*
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Karate for Christ/Heiwa Karate-Do Registration