NORTH CREEK MARTIAL ARTS

ABILITY UNLIMITED OF WASHINGTON

ENROLLMENT FORM

Name____________________________________________

Home Phone ________________ Work Phone_________________

 Parent’s Name (If under 18) ________________________________

 Address_________________________________________________________

 City _____________________________

State _____________ZIP___________

 E-mail Address __________________________________________

Date of Birth ___________Age______

Occupation_______________________

Have You Had Previous Martial Arts Training? ______

 How Long? _________ Type or Style _________________________

How did you learn of our program?
FLYER___   NEWSLETTER______   WEBSITE _______  DEMONSTRATION __________  OTHER ___________

 Referred by______________________________________________

 Do you have any medical problems or specific disabilities? _______

 PLEASE DESCRIBE IN DETAIL

________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Release:  I hereby consent to participate in activities offered by North Creek Martial Arts and Ability Unlimited of Washington.  It is hereby agreed that I or my children waive and release all right and claims for damages that I may have at any time against the school, it’s representatives whether paid or volunteer for any injury or damages in connection with the karate program or North Creek Martial Arts and Ability Unlimited of Washington.  The risks involved in respect to such a program are fully understood.

Permission for Medical Treatment:  I confirm that the above named person is in good health.  I hereby authorize simple first aid and consent to any x-ray, exam and medical or diagnosis which is deemed necessary.

SIGNATURE___________________________________DATE______________