North Wind Martial Arts 25-26 After School Registration Form

2025 After School Karate Application Form
ALL FEES PAID AT THE BEGINNING OF THE WEEK
Registration Fee = $50 (includes uniform)
Full-time Weekly Fee = $100 (This weekly fee is subject to change due to weeks with holidays such as Spring Break week)

Part-time Daily fee is $33 per day (Days when school is off the full-day rate is $40) Drop off = $85 for the week/$25 per day
Name*

Student's First NameStudent's Last Name
Age*
Date of Birth*

MonthDayYear
Date
MaleFemale
Grade*
School*
Teacher
YesNo
Start date*

MonthDayYear
Date
Weekly payment amount*
Student lives with*
Both
Mother
Father
Other
Mother's Name*
Mother's Email*
example@example.com
Cell Phone*
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Zip
Father's Name*
Father's Email*
example@example.com
Cell Phone*
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
Address (if different from student's)

Street Address

Street Address Line 2

CityState / Province

Zip
Emergency Contacts: Students will be released only to the custodial parent(s) or legal guardian(s) and the persons listed below. These persons may also be contacted in case of an emergency in which the custodial parent(s) or legal guardian(s) cannot be reached:
Emergency Contact Name 1*
Phone Number(s)*
Format: (000) 000-0000.
Emergency Contact Name 2*
Phone Number(s)*
Format: (000) 000-0000.
Emergency Contact Name 3
Phone Number(s)
Format: (000) 000-0000.
Medical Information: I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if custodial parent(s) or legal guardian(s) cannot be
Initial*
Hospital Preference
Insurance Information*
List any medical conditions we should be aware of:
Medical Conditions*
Initial*
List any medication(s) your child is taking at this time:
Medications*
Initial*
Allergies, special dietary needs, or other areas of concern:
Allergies*
Initial*
MARTIAL ARTS BACKGROUND/HISTORY

Has your child studied martial arts in the past?
NoYes
If yes what style and how long
HOW DID YOU HEAR ABOUT NORTH WIND MARTIAL ARTS ACADEMY*
LIABILITY WAIVER
Student (or legal guardian/parent of student) hereby represents that he/she is physically fit to take the prescribed course of instruction, that he/she has had an opportunity to observe and/or participate in the art of self-defense prior to the signing of this agreement, and that no oral or written representations have been made to him/her except as expressly written in this agreement.
Initial*
Student further acknowledges the existence for the potential of significant personal injury as a result of participating in an activity such as Karate, Judo, but not limited to: Fitness Kick-Boxing, Jiu-Jitsu, Self- Defense and Personal Fitness Training, and that he/she is assuming this risk without liability to the School or instructors by executing this agreement and participating in said course(s) of instruction.
Initial*
Failure to take advantage of classes offered does not relieve the Student of his/her obligation to pay his/her course in full. Student is obligated to make all payments whether or not he/she attends class. All lessons are subject to schedules to be established by the School from time to time.
Initial*
Student must notify the School in writing within ten (10) working days of any change of address and immediately for any change of telephone number.
Initial*
Student (or legal guardian/parent of student) has read and understands all of the contractual terms set forth in this agreement.
Agreement accepted by Purchaser*
Date*

MonthDayYear
Date
North Wind Martial Arts Academy Signature*

Clear
Date*

MonthDayYear
Date
Permission to Use Photograph/Video

I grant North Wind Martial Arts Academy, its representatives and employees the right to take photographs and/or videos of my child/or childrento use for promotional material for the business and/or associated field trips. I agree that North Wind Martial Arts Academy may use such photographs of my child(ren) with or without any name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.

I have read and understand the above:
Printed name*
Signature*

Clear
Date*

MonthDayYear
Date
Permission to Use Photograph/Video

I grant North Wind Martial Arts Academy, its representatives and employees the right to take photographs and/or videos of my child/or childrento use for promotional material for the business and/or associated field trips. Iagree that North Wind Martial Arts Academy may use such photographs of my child(ren) with or without any name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.

I have read and understand the above:
Printed name*
Signature*

Clear
Date*

MonthDayYear
Date
No
Should be Empty:

ALL FEES PAID AT THE BEGINNING OF THE WEEK

LIABILITY WAIVER