student
REGISTRATION FORM

Karate Belt
Which program you interested/enrolling into? (Check all that apply)

In case of emergency, please contact:

MEDICAL INFORMATION

Students who have asthma, diabetes, epilepsy, heart disease, or any chronic medical conditions, please provide the following, so we can most effectively handle an emergency:

If needed, please include a sealed envelope containing an emergency dose of treatment with the student's name on it. 

WAIVER OF LIABILITY

                                                                                   will be participating in classes at Ojishi Martial Arts and Wellness. Without further consideration, I hereby waive any and all claims against Ojishi Martial Arts and Wellness, Jay Hawkins, or any other instructors or students which may arise as a result of injury to myself and/or the aggravation of prior existing conditions by way of my participation in classes and activities at Ojishi Martial Arts and Wellness.

PHOTO RELEASE

I,                                                                 give permission for photographs taken of

at Ojishi Martial Arts and Wellness and its functions to be used for publicity.

Thanks for submitting!