Bear Dojo Student Information Form

Student Name

First NameLast Name

Parent/Guardian Name (if student is a minor)

First NameLast Name

Student Birthday

Date

Student Gender

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Contact Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Above Emergency Contact

Hospital/Physician Name

Medical Conditions/Allergies/Etc.

Liability Statement

I understand and agree that Karate/Self Defense and other activities may involve physical contact and may result in injury and I do hereby fully release and acquit Allan Nolan, Bear Dojo or Marek Chromik, Eclectic Ground LLC as well as Greenwood Terrace Management, their visiting instructors or students from any and all responsibility and liability for any and all personal injuries, loss of personal property, or any casualty that may result from my participation in any program offered at this location.

Furthermore, I waive all rights to claims for damages I have against Bear Dojo and its representatives, successor, and assigned for any and all injuries or theft suffered either by myself and/or the aforementioned student and/or other family members while being transported to or from the dojo, or while participating in or observing events at or sponsored by Bear Dojo.

That there are no refunds for registration fees or purchased uniforms or equipment.
I acknowledge the contagious nature of COVID-19 and other contagious diseases and viruses and voluntarily assume the risk that I and/or my children my be exposed to or infected by COVID-19 by attending and participating and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 and other contagious diseases and viruses may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, independent contractors, volunteers, and program participants and their families. I release Bear Dojo, it’s instructors, independent contractors, and all associates from liability or harm, injury, or death pertaining to COVID-19 and other contagious diseases and viruses.
Students may not be allowed to participate in self-defense and/or partner drills if they are wearing any type of jewelry or watches.
Students may not be allowed to participate and no refund will be given if they do not follow instructions or act in such a way that is unsafe for them and/or other students. This will be solely at the instructor’s discretion.
Karate/Self Defense is a physical sport which is conveyed to muscle memory through tactile senses. Therefore, I understand that instructors will use imagery, touch, and sound kinesiological principles to convey correct stance and motion.
Students will not be allowed to participate until the release form is signed.

Liability Statement

Check for Understanding

I understand that Kojosho and the Kojosho Forms are protected under Federal and State copyright and trademark laws and are not to be performed at any public event or shared on social media without the express written approval of the Chief Instructor.
Participation Information/Release Form needs to be completed and signed by parent or guardian.
Please be on time to class. Students who are late to class will be required to do some warm up exercises and stretching before joining class to make sure muscles are ready to work. If too much of the class is missed, it may not be counted as attendance toward testing.
While being stretched outside of your comfort zone is beneficial, if we ask you to do something that really makes you uncomfortable, please communicate and let us know.
Please do not wear watches or jewelry of any kind to class. For your safety and the safety of others, students wearing watches and/or jewelry will not be allowed to participate in self-defense, sparring, or any other interactive drills.
*Please have your hair pulled back out of the way, especially when sparring and doing self-defense. It is not safe if you cannot see properly or it gets tangled in someone's fingers.
Wear something comfortable and easy to move in.
Students not wearing their complete gi will line up at the end, no matter their rank.
Please do not wear jeans to class (even under your gi) as they restrict movement.
Be respectful of the instructors and helpers.
Parents, siblings, and students waiting for your class, please keep your voices down. We are conducting a class and loud voices can be distracting and make it difficult for the teacher to be heard.
Come with a good attitude ready to have fun!

Check for Understanding

I, the parent or legal guardian of the member listed above, have read the above waiver and agree to its terms on behalf of my son/daughter.

Today's Date

Date

Student Signature (parent or guardian if student is a minor)

Bear Dojo Student Information and Release Form