Classes
At the Orchard
APPLICATION FOR
CHILDREN’S / TEEN AIKIDO PROGRAM
Student Name
______________________________________
Age _____
School
____________________________________________ Grade _____
Parents/Guardians ___________________________________________________
Address
_______________________________________________________
_______________________________________________________
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
_____________________________________________
Date ___________
Parent/Guardian Signature
_______________________________________________
Date ___________
