Student Registration Form

Registration Form and Waiver

If you have already submitted a request for a free trial class or would like to enroll in a normal class. This form is required for all existing members and guests before getting on the mat. Please fill in the fields below and hit SUBMIT.

All visits are by appointment only - adults visiting for trial or normal classes will be screened against a public sexual offender registry.

General Information and Emergency Contact

* Indicates required field

Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Registering for which Class/Classes? *

Emergency Contact *

How did you hear about us? *

Comment or question *

RELEASE FROM LIABILITY FORM
Yushinkan Dojo L.L.C.
Please complete, sign, and date below.

I,	Full Name of participant (waiver) * Name of person participating

(hereinafter “participant”), in consideration of being allowed to participate in classes/activities at Yushinkan Dojo L.L.C. agree to hold harmless Yushinkan Dojo L.L.C., their members, agents, employees/instructors, successors and assigns from and against any personal injury, death or property damage that may result because of my participation in any/all Yushinkan Dojo L.L.C. activities. I fully comprehend and agree that there are inherent risks involved with any physical activity, especially martial arts, and I assume all risks of personal injury, including death, resulting from my participation. I further state that I have no known physical or mental health limitations or problems that would prevent me from participating in any/all Yushinkan Dojo L.L.C. activities. Once again, I hereby assume all risks of personal injury, including death, resulting from participation.

The parent or guardian of an applicant who is a minor hereby agrees to hold Yushinkan Dojo L.L.C., their members, agents, employees/instructors, successors and assigns harmless from any liability from physical injury, death or property damage resulting from classes/activities at Yushinkan Dojo L.L.C.. The parent or guardian fully comprehends and agrees that there are inherent risks involved with any physical activity, especially martial arts, and assumes all risks of personal injury, including death, resulting from the minor’s participation. The participant, and/or parent or guardian of the participant, further agrees to bind himself/herself, his/her heirs, administrators, and executors to repay and indemnify Yushinkan Dojo L.L.C. any sums of money that Yushinkan Dojo L.L.C., their members, agents, employees/instructors, successors and assigns may hereafter become liable to pay on behalf of the participant for any reason whatsoever.

Participant Signature (Full Name) waiver: *

Parent or Guardian (if participant is a minor) Signature (Full Name) waiver: *

Date (of Waiver signing): *

Public Sexual Offender Registry Search Agreement *

By marking this box, you are agreeing to a public sexual offender registry check, and that Yushinkan Dojo LLC reserves the right to refuse admittance based on the result of this background check.

Submit