Saturday Ninjas in Nature Drop-In Training Registration

Student Name *

First Name Last Name

E-mail *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number

Student Age

Additional Family members? Please add their names and ages

Day you are planning to attend? Note- we train on the second Saturday of the month. 9:30 -12:30. *

- Month - Day Year

Is this your first time training at the Saturday NiN Program? *

Yes No

Are you a parent/guardian registering a youth student? *

yes no

Parent/guardian name

First Name Last Name

Emergency Contact Name

First Name Last Name

Emergency Contact phone number

- Area Code Phone Number

Does the student (youth or adult) have any allergies or pertinent medical conditions? *

yes no

Please describe any allergies or pertinent medical conditions *

Medical Release

I understand that in the event the student listed above is significantly injured, ill, unconscious, and/or no one otherwise authorized to contact Emergency Medical Service (EMS) personnel is present; it will be the practice of the instructor(s) to contact EMS personnel on behalf of the student. I give my permission for responding EMS and hospital personnel to begin necessary treatment. Furthermore, I agree to be financially responsible for any and all medical treatment for student listed herein.

Name of consenting adult or parent/legal guardian reading this medical release *

First Name Last Name

I agree to the above medical release *

agree

Informed Consent Liability Waiver

By choosing "agree" below this form I agree that I have been informed that I should not participate in any activity if I have any doubt or if I am uncertain as to my current medical condition. I understand that I should always seek medical advice before starting any physical training program.

I understand that the activities in which I participate are physically and mentally intense and may require extreme exertion and give rise to the possibility of injury or death. I hereby certify that I am in good health and do not suffer from any heart condition or other ailment that could be exacerbated by the exertion involved in the activities in which I participate. I confirm and agree that I am fully aware of the risk and certify that I (my child/legal ward) am physically able to participate in this program’s activities. I further agree that I will comply with all the rules, regulations, and instructions given to me by any program instructor, assistant instructor, or corporation official.

Further, I (on behalf of my heirs, personal representatives, executor, and administrator) hereby waive, release, remise, covenant not to sue and forever discharge from any claims and liabilities whatsoever without limitations Mark Roemke, Robbin Finnerty, Santa Cruz Bujinkan, Ninjas in Nature, Pathways Dojo, The NEST and its owners, or any operator, official, supervisor, officer, participant, agent, instructor, judge, volunteer, sanctioning entity, or employee from any expense, damage, loss, injury, or liability (including attorney fees) due to my decision to participate in any activity, class, seminar, or other event sponsored by any of the above noted entities or persons. I agree to indemnify and hold harmless the above mentioned entities/persons for any and all loss, injury, damage, claim, and liability. I confirm that I either have specific insurance to cover any injuries that I may sustain or that I have chosen to participate in these activities without any insurance coverage and agree to assume full responsibility of risk and bodily injury, death, and property damage. I hereby assume any and all risks, known and unknown, which may arise from my decision to participate in this activity. I agree to allow Ninjas in Nature, Pathways Dojo and affiliates to utilize any photograph, audiovisual recording, or other digital media taken of me or my child at any class or event. I understand that I will not be compensated in any way for use of any such media.

I hereby certify that I am at least 19 years of age. If the student is 18 or younger, the parent(s) and/or legal guardian (s) must select the "agree" button below.

Name of consenting adult or parent/legal guardian reading this waiver *

First Name Last Name

I agree to all the information of the Informed Consent Liability Waiver above *

agree

If this is your first time training with us, in addition to the first FREE training Saturday, would you like to also pay for additional sessions?

yes not at this time

My Products

Saturday NiN Drop-in Registration $ 40.00

Number of people you are registering

Discount Register for 2! Buy two visits or one visit for two people. $ 70.00

Total $ 0.00

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Credit Card Number	Security Code
Expiration Month	Expiration Year

Saturday Ninjas in Nature Training Registration

We are excited that you are going to join us to train at the NEST in Felton. For a limited time, the first training session is FREE! For questions, please contact nin@pathwaysdojo.com

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