Classes At the Orchard
APPLICATION FOR CHILDREN’S / TEEN AIKIDO PROGRAM
Student Name ______________________________________ Age _____
School ____________________________________________ Grade _____
Mailing address (if different) ___________________________________________
___ I would like to receive announcements by email
Email address ______________________________________________
Phone #’s: Home: ______________________ Cell: ____________________
Work: _____________________ Other: ____________________
Please note that my child _______________________________________________
Medical : medication, health concerns, injuries _______________________________
Alternative .Emergency Contact __________________________________________
Phone # ____________________ Relationship __________________________
How did you hear about the Aikido program?
WAIVER AND RELEASE
I understand that martial arts training, which includes throws, falls, contact sparring and weapons training, has inherent risks and I hereby indemnify, hold harmless, release and forever discharge Avella Orchard, Classes at the Orchard, its instructors and students, and the owner(s) of the property, from any and all claims and demands whatsoever which I, my heirs, representatives, executors, administrators or assigns have or may have against these parties by reason of any accident, injury, death or other consequences arising or resulting directly or indirectly from my participation in classes or other activities conducted under the auspices of Avella Orchard, and occurring during my participation or any time subsequent thereto.
I have read and agree to follow the program guidelines and understand that failure to comply with them may result in immediate withdrawal from the program.
Student (if over 12) Signature _____________________________________________
Parent/Guardian Signature _______________________________________________