Student Name: DOB:
Parent Name: D/L#
E-Mail Address:
Address:ZIP Home#
Employer: Work#:
Employer Address: City & Zip:
Spouse Address:D/L#
Address: ZipHome#
Employer: Work #
Employer Address:City & Zip
Emergency Contact: Phone
Please Note: To reserve your place here in the Martial Arts & fitness Training Program, your payment is due on the 1stday of each month for monthly payments. Weekly payments are due at the end of the week, prior to each week of attendance. You will have a grace period, which is until the following Monday. In the event of nonpayment by grace due date, there will be a $5 per day late fee and we cannot provide service until the payment is made. A $35 fee will be charged for all Returned Checks. And after two, you will no longer be able to pay by check. And at such time that we begin to accept Credit Card payments, the fees assessed us for accepting credit cards payments will be reversed back to you.
No Refunds will be made! Initial X
Please Note: No Student may participate in the structured karate program unless a written agreement is first signed by the parent or legal guardian of the student. The Student Agreement states that Synergy Martial Arts and Fitness is a martial arts School and NOT a daycare, and that the Dojo does not provide or accept any responsibility for supervision or care beyond the teaching of Martial Arts. The Dojo’s Stock and trade is not Supervision andcare, rather the Dojo’s intent is to teach martial arts physical skills as well as philosophical character building skills. The Student Agreement further acknowledges that the Dojo is a Drop-In Facility, in as my child is free to come and go and that each student is under the sole direction of the parent or legal guardian for arrival and departure and that the Dojo does not accept any responsibly for the management and control of attendance by a student. Parents must have no expectations of any Child Care to attend this program. The Dojo is granted the right to eject any student based on misconduct or non-interest.
Non-Compete: It is prohibited for any Student, buyer and or guests of such to conduct any commercial business or activity, or solicit any business competitive with that of our Dojo, from or about our Dojo premises without prior, express, written consent of the owners of the Dojo within a 25 mile radius for a period of 5 years. The Dojo has the right to recover any revenues received by Student, buyer and/or guests in violation of this policy, as well as attorney’s fees, court cost, etc. incurred. Student, Buyer and /or guest may not subscribe to any such business activity.
Medical Information
Child’s name:DOBS.S.#
Emergency Contact:
Emergency Contact address:
Emergency Contact’s phone#:
Doctor’s Name:
Doctor’s Address:
Doctor’s Phone#:
Dentist’s Name:
Dentist’s Address:
Dentist’s Phone#:
Medical Insurance Carrier and Member number:
Preferred Hospital:
Known Medical Conditions:
Known Allergies:
Current medications:
NOTE:By signing you acknowledge that the information above is correct and current. Any false information may result in termination of this application. By signing this application the parents and all parties recognizes that the school is not held liable for any injuries that may occur during the course of training. We will strive to protect all students while here at our Dojo at all times. Basic medical care can be found in our first aid kit available for minor injuries only.
Authorization Signature: X Date:
Must be read, understood and be signed by legal participant, or guardian, the Waiver Release, Indemnification, Hold Harmless Agreement Form to participate in Program!