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Karate for Christ of Michigan

Student Enrollment Information

Student Name:  Last_____________First______________Middle____________Phone#_______

E-mail__________________ Age _______Date of Birth _______Height _____Weight ______

Home Address ____________________City & State __________________Zip Code_________

Other E-Mail Address or cell #_____________________________________________________

If Minor-Parent or Guardian Name: Last ________________First ______________Middle_____

Is Applicant under a Doctors Care: Yes ___No___ Any allergies: ________________________________

Name Any Broken Bones, Injuries, or illnesses____________________________________________________________

If Applicant attends school, Name of School  __________________________________________________Grade _____Teacher’s Name__________________________

Previous Training in martial arts : Style_____________ Rank_______

Church attending if any: _________________________________________________________

Liability Release Form

I, the undersigned, my heirs, executors, administrators, agents, and assigns herewith assume all risk of personal injury or death which I might experience or be exposed to by my presence, attendance, and participation in the activities of the above mentioned Karate for Christ of Michigan, instructors, officers, employees, and agents from any and all liability, including claims and suits of law or in equity for personal injury , including concussions, broken bones, or death or any other loss that has occurred in the past or might occur in the future as a result of my presence, attendance, and participation in the activities of Karate for Christ of Michigan. I also understand that the Karate for Christ of Michigan assumes no responsibility for the loss of personal property.

I, certify that I am in good health. If I have any health or physical impairments that may limit or restrict my participation in the activities of the Academy and the practice of Hapkido, they are described fully above.

I also will allow KFCOM to use pictures taken in class or at seminars on its website or promotional materials. (Yes)  (No)

Signature of Applicant______________________________________

Signature of Parent or Guardian__________________________________

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