STUDENT APPLICATION & RELEASE FORM

 

Student’s Name:________________________________   Age: ______  DOB: ___/___/___      Phone:  (_____)_________________

 

Address: ________________________________________________  City: _______________________  Zip:__________________

 

Occupation: _______________________________________             Work/ Emergency Phone: (_____)________________________

 

E-mail Address: _______________________________@_________________________________ (For updated/new information on our programs)

 

 

Physical injuries or body problems (past or present): _____________________________________________________________

 

How did you find out about our school?         _______________________________________________________________________

 

Do you have any martial art experience?       _______________________________________________________________________

 

What martial art(s) are you interested in?       _______________________________________________________________________

 

 

 

Check area(s) you are most interested in:

 

¨     Strength                                                                         ¨  Sparring                                                                          ¨  Concentration

¨     Flexibility                                                                       ¨  Weapons                                                                        ¨  Focus

¨     Coordination                                                                                ¨  Forms                                                                              ¨  Determination

¨     Conditioning                                                                 ¨  Breathing Forms                                                           ¨  Patience

¨     I would like to be notified of any free monthly seminars. 

(Some past seminars include:  Tai Chi, Oriental Medicine, Self Defense, Health and Wellness, Strength and Flexibility)

 

Children Classes ONLY
PARENTS:   Please indicate which lesson time(s) and day(s) you would like your child to attend regularly. _____________________________________________
_________________________________________________________________________________________________________________________


 

 

 

Checks payable to:  AGSMA

                                                                                                                                                                               

 


RELEASE FORM

The student signing this waives any cause of action or claim against Eric Protas AND/OR  Protas Development Inc. ( D.B.A:  PMAI (or Protas Martial Arts Instruction.) or John Neilson D.B.A. the Allied Gardens School of Martial Arts; their officers, directors, instructors, and employees for any injuries received resulting from instructional services rendered.  The student signing this acknowledges that they should have received permission from a medical doctor following a general physical examination approving the student’s participation in these instructional services.  Please read and initial the reverse side hereof.

 

Student’s Signature (Over 18): ____________________________________________________                          Date: ____/____/____

 

                                Print Name:  ____________________________________________________

 

PARENTS/GUARDIAN: Authorization if Student is a Minor

 

Parent’s Signature: __________________________________ Relationship: ______________            Date: ____/____/____

 

 

                            Print Name: __________________________________

Please read and initial the reverse side hereof.

 

 

Student/SCHOOL representations and release of liability:

The member applying warrants and represent that he/she/minor or student is in good physical condition and has not been advised by any Physician or Medical Facility that participation in the applied for course of training will in any way be adverse to the well being of the student.  Furthermore, member represents that the student is able and allowed to participate in exercise and various martial arts curriculum which is provided by SCHOOL.  Student/parent/guardian understands that by participating in the martial arts program or by use of the facilities or equipment covered by this contract does present the possibility of accidental injury.  Student/parent/guardian assumes all risk associated with such participation within this program and holds SCHOOL harmless for any such injury or occurrence.  In addition, student/parent/guardian agrees to indemnify SCHOOL from any and all liability which may arise against SCHOOL by such member or though any other third party as a result of training received by SCHOOL or by use of SCHOOL’s facilities or equipment.  Student/parent/guardian understands that during the course of instruction, employees or higher degree student instructors of SCHOOL will be engaged in a course of conduct requiring physical contact, and he/she (or parent or guardian) gives full consent to such contact as is required by the training.  It is understood that due to the nature of the training which is being provided by SCHOOL that accidents do from time to time occur.  While all precautions will be taken to assure the safety of all students, it is impossible to guarantee that such accidents will not occur.  In the event that you are involved in an accident which subjects you to any injury, you agree to hold SCHOOL, Protas Development Inc (DBA: Protas Martial Arts Instructor (PMAI)) and Eric Protas harmless; you further agree that neither you, a parent, a guardian or any other financially responsible person will take action against SCHOOL, Protas Development Inc (DBA: Protas Martial Arts Instructor) or Eric Protas as a result of such injuries.

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Age or Parental Consent Certification:

By signing this contract, you are certifying that you are either of legal age or that you are signing this contract as the parent or legal guardian of a minor, and by signing this contract on behalf of any minor, you hereby agree that you shall be responsible for all payments due hereunder and that you will indemnify and hold SCHOOL harmless for any injuries, losses, or damages sustained to anyone as a result of the minor’s participation in this program of instruction.

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Governing Law:

This agreement shall be construed in accordance with the laws of the State of California without regard to its conflict of laws principals.   This Agreement shall constitute the entire understanding with respect to the subject matter hereof and may be modified only in writing signed by both STUDENT and SCHOOL.  If any provision of this Agreement is determined to be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.

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Bad Check Charges: 

It is agreed that in the event that PMAI receives any check returned as NSF or is returned by bank for any other reason, that student/parent/guardian will be responsible for a charge of $6 made payable to PMAI.

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Default/Collection:

All accounts 30 days past due will be subject to late fees of $10.  We can waive or delay enforcing any of our rights under this contract without losing them.  

Initials______