First Month Enrollment Form

Parent/Guardian Information

Required for new student registrations. If you are an adult student, please list yourself as both the parents and the student.
Parent/Guardian Full Name*

First NameLast Name
Additional Parent/Guardian

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
EmailPhone callText message
Student Information

If registering multiple students, please complete this form individually for each student. Thank you!
Student Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please list any medical conditions.*
Asthma, Autism spectrum, ADHD, etc. or "None"
What school does your child attend?
Student Goals
ConfidenceHealth and FitnessFocusResponsibility and CommitmentRespectSelf-DefenseFriends/CommunityAnti-BullyingAnger Management
Final Question: Do you have a teen or adult in your family interested in karate training?
We’ll be in touch to launch our Teen/Adult Class.
Agreements & Signatures

Please review and complete the required acknowledgements and electronic signatures.
I acknowledge that participation in karate and related activities involves inherent risks (including physical injury). I agree to assume these risks for the student and release and hold harmless Willamette Valley Karate, its owners, instructors, employees, and agents from claims or liability arising from participation, except where prohibited by law.

I grant permission for Willamette Valley Karate to capture and use photos and/or video of the student for promotional and informational purposes (e.g., website, social media, printed materials). I understand no compensation is provided and I may revoke permission in writing for future use where applicable.

I acknowledge and agree that all tuition payments are non-refundable, including payments made for the one-month trial program.
I have read and agree to the terms above.
Waiver of Liability Electronic Signature*

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First Month Promo (K-5)

1 Month of Karate Classes, 1 FREE Dojo Shirt, 1 FREE Dojo Sling Bag

$39.00 Shirt Size

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Parent/Guardian Information

Student Information

Student Goals

Agreements & Signatures