MEMBERSHIP REGISTRATION FORM

Date: _____________

STUDENT/MEMBER INFORMATION

Name: _________________________________________________________
Last                                   First
Date of Birth: _________________________    Sex: ______________________
Address:________________________________________________________Home Phone: ____________________ Work Phone: ______________________ Mobile Phone: ________________ Email:_____________Facebook:__________

MEDICAL INFORMATION

1. Do you have any history of heart trouble? Yes ________No________
2. Have you ever experienced pain or tightness in your chest? Yes ________No________
3. Have you ever had a stroke? Yes ________No________
4. Do you have high or low blood pressure? Yes ________No________
5. Do you often suffer from severe dizziness? Yes ________No________
6. Do you have diabetes? Yes ________No________
7. Are you pregnant? Yes ________No________
8. You have asthma? Yes ____ No ____ Do you need an inhaler? Yes ___ No ___
9. Do you have epilepsy or seizures? Yes______ No______

If you answer ‘Yes’ to any of the above questions, you may need a physician release to utilize the Karate Dojo Club, classes, facilities, activities, and/or tournaments, otherwise I/we will be practicing on my/our own risk and will take fully responsibility. ______ (Student/Member/parent Initials)

EMERGENCY CONTACT
Name: ________________________________________________________ Home Phone: ___________________________________________________
Relationship: ___________________________ Work Phone: _____________ Email: _________________________

NOTICE TO STUDENT / PARENT / MEMBER
By registering for this program, I acknowledge that the activities carried on have certain risks. I have independently reviewed and evaluated the risks and am determined to engage in the program with full knowledge and acceptance of t risk. I expressly assume all risks of injury and WAIVE, on behalf of myself, my heirs, and assigns, any claims against the SJ Karate –Club (SJK) and/or affiliated dojos inside or outside the States of Utah and Oklahoma, their shareholders, officers, instructors, owners, employees, visitors, students, parents, volunteers, agents in the United States, arising out of any loss or injury while inside or outside of the premises or related to the activities in this program, whether such loss or injury results from the negligence or not of the SJ Karate –Club (SJK) inside or outside the State of Utah and Oklahoma, their shareholders, officers, instructors, owners, employees, visitors, students, parents, volunteers, agents in the United States, or some other cause. I further agree to hold harmless SJ Karate (SJKD) and affiliated or related dojos outside or inside the State of Utah and Oklahoma, their shareholders, officers, instructors, owners, employees, visitors, students, parents, volunteers, agents in the United States, for any injury or property damage resulting from my participation or my child’s participation in this program, waiving ANY and all my rights for ANY law-suit, including ANY costs of defense, court fees, and attorney fees. If signing on behalf of a minor, I agree to hold harmless the SJ Karate (SJKD) and/or affiliated dojos inside or outside the State of Utah and Oklahoma, their shareholders, officers, instructors, owners, employees, visitors, students, parents, volunteers, agents in the United States, for ANY and ALL claims asserted by or on behalf of the minor, or otherwise arising out of the injuries or death of the minor, including defense costs and attorney fees _______ (parent/student initials)

Note: Occasionally during training, specials seminars, or tournaments, we enjoy taking pictures of the event and would like to be able to include these on our website, Facebook, or posters for advertisement.

________ (Student/Parent/Member Initials) I/We grant permission to SJ Karate Dojo (SJKD) & the photographer, to reproduce the photographs and/or videos taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.

Fees are not refundable. ________ (Student/Parent/Member Initials)

____ I (We) hereby authorize SJ Karate Club, and/or his representative David A Crosby, to initiate monthly debit entries from the account(s) above. This authorization for automatic debit shall remain in full force and effect until this membership is cancelled in accordance with the cancellation terms provided above and on the back of this Membership Agreement.
____ I/WE will make my/our monthly payments.
____ I (We) hereby acknowledge that I (We) have read, understood, and have agreed to all the terms of this Membership Agreement, including the additional terms on the back of this Membership Agreement and that I (We) have received a signed copy of this Membership Agreement.
____ I (We) hereby acknowledge the Dojo may be closed between 3 to 10 days when attending tournaments out of the State, and make-up classes may not be offered.

___________________________________
Student / Member
_________________________________
Approving Officer Agent
___________________________________
Parent / Guardian
_________________________________
Date
______________________________________________
Billing Party (if different from Student/Member/Parent/Guardian)