please fill out completely! one-time ...€™s shotokan karate jiu–jitsu enrollment form please...

MO’S SHOTOKAN KARATE JIU–JITSU ENROLLMENT FORM PLEASE FILL OUT COMPLETELY! ONE-TIME ENROLLMENT FEE IS $50 590 East Chatham St, Ste 108, Cary, NC 27511 (919) 461-9708 PERSONAL INFORMATION Last Name ___________________ First Name ____________________ M.I. ____ Nickname_________ Age _________ Date of Birth _______________________ Address____________________________________ City ________ State _______ Zip ________ Home Phone ________________________________ Cell Phone _______________ Email Address______________________________________________ Any significant health concerns that might affect my participation: ____________________________________________________________________________________ ____________________________________________________________________________________ Special Needs (Allergies, Medication, etc.)__________________________________________________ Physician __________________________________________________ Phone ___________________ Emergency contact person ____________________________________ Phone ___________________ Participation Waiver (Must be completed by parents If Under 18) I / We the undersigned , waive, release the Mo’s Shotokan Karate and its staff from all rights and claims for damages, injury or loss to person or property which may be sustained or occur during participating in Jiu-Jitsu activities, whether or not damages, injury, or loss is due to negligence. It is also agreed that during my participation in the Jiu-Jitsu program MSK or any staff shall not be responsible or liable for loss or damage to any of my personal properties including my automobile and its contents. It is also agreed that any damages to MSK facility or property caused by me are my sole responsibility. Signed : __________________________________ Date : ___________________ 590 E Chatham St, Ste 108, Cary , NC 27511 – (919) 461-9708

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MO’S SHOTOKAN KARATE JIU–JITSU ENROLLMENT FORM

PLEASE FILL OUT COMPLETELY! ONE-TIME ENROLLMENT FEE IS $50

590 East Chatham St, Ste 108, Cary, NC 27511 (919) 461-9708

PERSONAL INFORMATION

Last Name ___________________ First Name ____________________ M.I. ____ Nickname_________ Age _________ Date of Birth _______________________ Address____________________________________ City ________ State _______ Zip ________ Home Phone ________________________________ Cell Phone _______________ Email Address______________________________________________ Any significant health concerns that might affect my participation: ____________________________________________________________________________________ ____________________________________________________________________________________ Special Needs (Allergies, Medication, etc.)__________________________________________________ Physician __________________________________________________ Phone ___________________ Emergency contact person ____________________________________ Phone ___________________

Participation Waiver

(Must be completed by parents If Under 18)

I / We the undersigned , waive, release the Mo’s Shotokan Karate and its staff from all rights and claims for damages, injury or loss to person or property which may be sustained or occur during participating in Jiu-Jitsu activities, whether or not damages, injury, or loss is due to negligence.

It is also agreed that during my participation in the Jiu-Jitsu program MSK or any staff shall not be responsible or liable for loss or damage to any of my personal properties including my automobile and its

contents. It is also agreed that any damages to MSK facility or property caused by me are my sole responsibility.

Signed : __________________________________ Date : ___________________

590 E Chatham St, Ste 108, Cary , NC 27511 – (919) 461-9708