Florida Aikido Center Llc Registration Form printable pdf download

Florida Aikido Center,

LLC

Registration Form & Waiver

Date:

Name:

Address:

Phone Number(s)

(home, cell & work):

Email Address:

(please print clear enough to read)

Date of Birth:

Emergency Contact –

Name & Phone Number(s)

(home, cell & work):

Have you ever studied a martial art before?

If yes, which style and for how long?

If participant is under age 16, who is

authorized to pick him/her up?

Are there any medical or other health factors that might

e.g.

affect you/your child’s performance in this activity (

Please initial: Yes_____ No_____

asthma, allergies, fainting, dizziness, etc.)? I will immediately

(If yes and under the age of 18, a medical

inform an instructor of any medical or health factors

release is required.)

which may occur or develop which could affect my/my child’s

participation.

Are you/your child taking any medications that might affect

Please initial: Yes_____ No_____

you/your child’s performance in this activity? I will

immediately inform an instructor of any medications which

(If yes and under the age of 18, a medical

may be later prescribed which could affect my/my child’s

release is required.)

participation.

Photo Permission: Florida Aikido Center, LLC reserves the right to use both moving and

still images taken in class or events for instructional videos and/or advertisements without

Initial _______

my written consent.

I, the undersigned, acknowledge that I am voluntarily attending classes to obtain instruction in a martial art

involving strenuous exercise and personal body contact. I understand that because of this, there is always an

inherent risk of injury that cannot be eliminated. Such injuries may include, but are not limited to, pulled

muscles, dislocated joints, broken bones, permanent disability or even death and I hereby assume full

responsibility for all risks.

Florida Aikido Center, LLC will not exclude individuals with medical conditions that do not pose a medically

recognized threat to the health or safety to self or other students in the normal course of training. I understand

though, that there are some unavoidable circumstances where these conditions may require special caution on

Florida Aikido Center Llc Registration Form

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