Evening Enrollment Form

Student Evening Registration Form

Fill out the form carefully for registration
Student MUST BE 5 years or above to register for this program
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*

Area CodePhone Number
Date of Admission*

Parent/Guardian Name*

First NameLast Name
Mobile Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email*
example@example.com
Parent/Guardian Name

First NameLast Name
Mobile Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email
example@example.com

Name of Person to contact in case of an emergency if parents/guardian cannot be reached
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Phone Number*

Area CodePhone Number

I hereby authorizae the facility to allow my child to leave the facility ONLY with the following person(s); (does not include need to include parent/guardian listed above)
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

In the event that I cannot be reached arrangements for emergency medical attention. I authorize the facility director or person in charge to take my child to:
Medical Doctor

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital

TRANSPORTATION: I herby give my consent for my child to be transported and supervised by facility staff:*

GiveDo Not Give

I warrant and represent that I am in good physical condition and that I have no disability or ailment, (including pregnancy) which may prevent me from engaging in weight training, active or passive exercise or that will be detrimental to my health, safety, or physical condition if I engage or participate in such exercise and/or other activities with Central Texas Family Karate, I further warrant that if I have a prior history of disability, impairment, or ailment and engage or participate in such exercise and/or activities at Central Texas Family Karate, I do so at my own risk.
Initials*
I further acknowledge that physical exercise is a potentially dangerous activity and that I am voluntarily participating in the activities sponsored by Sensei Scott Bainton and Central Texas Family Karate with the knowledge of the dangers involved that include, but are not limited to, soft tissue injuries such as muscle strains and torn ligaments, broken bones, physical exhaustion, over-exertion, falls and physical contact with other participants and associates and users of the facilities. Knowing and appreciating these risks, I hereby agree to accept all risks of injury and death.
Initials*
I further understand that Central Texas Family Karate does not carry medical insurance and that to do so would make the cost of Central Texas Family Karate prohibitive. I understand and fully agree, that I am responsible for my own medical insurance and health care and realize that martial arts is a POTENTIALLY DANGEROUS ACTIVITY. Knowing this I voluntarily agree to participate in martial arts activities sponsored by Central Texas Family Karate. I agree to accept any and all risks of injury related to such martial arts practice and fully understand that I am responsible for my own medical insurance.
Initials*
Upon registration in this program I do hereby RELEASE for myself and my heirs, my executors and administrators, and WAIVE any and all rights to claims for damages arising from any illness, injury, or occurrences of aggravation thereof as a result of participating or connection with said programs, the owner, instructors, representatives, or facility, Central Texas Family Karate and/or all persons in the aforementioned employ, and agents of, or persons related there to.
Initials*
I understand that Central Texas Family Karate is not a daycare facility and is not licensed as such through the Texas Department of Family and Protective Services.
Initials*
I have carefully read this agreement and fully understand its contents. I am aware this is a release of liability and contract between myself and Central Texas Family Karate. I am also aware that there are NO REFUNDS FOR ANY PROGRAM conducted by Central Texas Family Karate. Any photographs or images of my likeness taken for or by Central Texas Family Karate may be used on any promotional or informational literature, web site, advertisement, or display without further consent or restitution. I sign this agreement of my own free will and with all my faculties and this release shall be binding upon my heir, successors, and legal representatives.
Initials*
Student Name*

First NameLast Name
I am the parent or guardian of the minor whose name appears above. I consent to the above terms on his/her behalf, and warrant that I have the authority to give consent and understand the content thereof
Parent Name*

First NameLast Name
Parent Signature: *

Clear
Date

MonthDayYear
Date
Should be Empty:

Student Evening Registration Form