Student Application

  • Student Application

  • Name of Student:
          

  • Nickname of the student:
          

  • Date of birth:
    Pick a Date   

  • Male or Female

  • School (If applicable):
       
          

  • Grade Level (If applicable):
       
          

  • Medical Provider Name and Number:
       
          

  • Does your child have any Special Needs? If so, please explain:
       
          

  • Does your child have any Medical or Health Concerns? If so, please explain:
       
          

  • Will your child take any prescribed medication or OTC medication during class hours? Yes No (If yes, please explain - asthma inhaler or an epi pen as an example)
       
          

  • Parental Information:

  • Name(s) of Parent(s) / Legal Guardian:
       
          

  • Address:
       
          

  • City
       
          

  • State
       
          

  • ZIP
       
          

  • Contact information

    Persons for contact

  • Phone (Daytime):
       
          

  • Phone (Evening):
       
          

  • Mobile
       
          

  • Primary Email
       
          

  • Name
       
          

  • Relationship
       
          

  • Person

  • Phone (Daytime):
       
          

  • Phone (Evening):
       
          

  • Mobile
       
          

  • Primary Email
       
          

  • Name
       
          

  • Relationship
       
          

  • Person

  • Phone (Daytime):
       
          

  • Phone (Evening):
       
          

  • Mobile
       
          

  • Primary Email
       
          

  • Name
       
          

  • Relationship
       
          

  • In case of an Emergency, and Parent cannot be reached, please notify:

  • Phone (Daytime):
       
          

  • Phone (Evening):
       
          

  • Mobile
       
          

  • Primary Email
       
          

  • Name
       
          

  • Relationship
       
          

  • Payment and Class Information:

  • Date of Sign-Up: 
    Pick a Date      

  • A 24-hour notice is required for cancellations or rescheduling. Missed classes are non-refundable unless there are certain emergency circumstances.

    Private Class Sessions as well as Semi-Private Lessons are 45 minutes or 75 minutes.

  • Please make check payable to David Hallford, LLC (there will be a $40 fee for all returned checks)

  • Please initial next to each:

  • I grant permission for my child/ward to participate in the self-defense classes. I acknowledge that this is a training which requires a number of physical activities and abilities.
  • Authorization to treat minor: In the event that I cannot be reached in an emergency, I hereby give my permission to call 911 and/or contact a medical facility or physician selected by the staff to secure proper treatment for my child and that I will be responsible for said expense.
  • Prescription or over-the-counter medication: I certify that I will have on file with the dojo, a current medical form stating all the medications that my child must take.
  • Individual Student Medical Insurance is not provided. In consideration of my child/ward's participation in the activity, I hereby waive all claims or causes of action against the trainer and their associations arising out of my child/ward's participation in the activity. I also hereby release, hold harmless, and discharge the trainer and all associations from all liability in connection therewith. In addition, I have been advised to obtain personal medical coverage and I agree to use my child/ward's personal medical insurance as a primary medical coverage payment if accident or injury occurs.
  • I also give permission for photographs and/or video to be taken of him/her while participating in this activity, and for these photographs and/or videos to be used for publicity purposes.

  • I have read and hereby certify that the above listed information is correct to the best of my knowledge. This waiver and release is freely and voluntarily given with the understanding that right to legal recourse against the trainer and associations is knowingly given up in return for allowing my child/ward's participation in the activity.

  • Date
     - -
  • Should be Empty: