Chris White Extreme Martial Arts - forms
 
Student Registration

Students Name:
Age:
Date:
Parent/Guardian (if applicable)
Full Address:
Home Phone:

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Cell Phone:

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Work Phone:

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Email
Child's Birthday:
Has your child studied Martial Arts before?
 Yes 
 No 
If yes, what style and rank:
Why do you want your child to study martial arts? (check all that Apply)
 Self-Esteem 
 Discipline 
 Exercise 
 Self-Defense 
 Other 
If other is checked, please specify:

Note:

Chris White’s Extreme Martial Arts strongly recommends all students to obtain a physical examination prior to participation. Parents/Guardians and participates also recognize the dangers connected with any physical activity and hereby acknowledge and voluntarily waive any rights or course of action of any kind whatsoever arising as the results of such activity from which any liability that may or would occur at Chris White’s Extreme Martial Arts and it’s instructors and employees and assistants on and/or off site. I further agree that any photos or video taken of myself or child(ren) in connection with Chris White’s Extreme Martial Arts can be used for publishing or promotional purposes without compensation at this time or any other time. I also acknowledge and voluntarily waive any rights or course of action of any kind as a result of any pictures or video taken of myself or child(ren) at this time and in the future.
Initial you have read the above: *

Medical Information (please list conditions and medications if any)
Person(s) authorized to pick up child(ren) other than Parent:
Person(s) NOT allowed to pick up child(ren):
Name of school student attends:

Parent, Legal Guardian, or Buyer's Information:

Employer Name and Job Title:
Address:
Driver's License Number and State:
Spouse's Name:
Spouse's Phone:
Person to notify in case of Emergency:
Emergency Phone number:

I understand that Chris White’s Extreme Martial Arts is a martial arts school and not a daycare in as such, their stock-in-trade is not supervision and care. Their intent is to teach martial arts, physical, and philosophical character building skills. I understand that Chris White’s Extreme Martial Arts is a martial arts school and is a drop in facility that as such, my child(ren) is/are free to come and go and if my child(ren) are to stay at their facility, it is because of my direction and not that of Extreme Martial art.
Authorization e-signature: *

Waiver and Release: You, the Buyer, and Student, agree that you are aware that the student is engaging in physical exercise, and the use of equipment and the use of Chris White’s Extreme Martial Arts Facility, training and instruction which can be dangerous to the student and could cause injury to the student. Student is voluntarily participating in these activities and Buyer and Student assume all risks of Injury to Student, which may result. Buyer and Student hereby waive and release any claim or right to sue Chris White’s Extreme Martial Arts, employees, or agents for Injury to Student. Buyer and student have carefully read this waiver and release, and fully understand it is a release of liability and damage of Chris White’s Extreme Martial Arts for any injury. Chris White’s Extreme Martial Arts will make no evaluation or recommendation whether Student or guests are sufficiently, physically fit for any exercise activities. It is always advisable to consult a physician before undertaking a physical exercise program, particularly martial arts.

Initial: *

Loss/Damage/Theft of Student’s Property: Chris White’s Extreme Martial Arts does not assume any responsibility for the loss, damage, theft of any property belonging to the Student. Buyer and Student agrees that Chris White’s Extreme Martial Arts and its employees are not responsible for or liable for any such property even if its loss, damage, or theft occurs on or about Chris White’s Extreme Martial Arts facility.

Initial: *

Waiver, Release and Permission to leave Chris White’s Extreme Martial Arts facility with Extreme Martial Arts Staff: Buyer and student acknowledge that as part of Chris White’s Extreme Martial Arts Summer Camp, all students will be off sight for a portion of each day. Buyer and Student also acknowledge that student will be involved in various martial arts related activities at the off sight locations. Student is voluntarily participation in these activities and Buyer and Student assume all risk of injury, which may result at off sight location/facility. Buyer and student waive any right to sue Chris White’s Extreme Martial Arts its employees, or agents, owners or trustee due to any injury which could result due to activities at any off sight location. Buyer hereby gives permission for student to travel to off sight locations to participate in martial arts related actives on a voluntary basis.

Initial: *

Buyer and Student will receive a schedule of activities for each day. This schedule will include the location of off sight martial arts activities.

Print Child's Name:
Print Parent/Legal Guardian Name:
Parent/legal Guardian e-signature: