Leadership Martial Arts

Leadership Martial Arts Membership Information
Personal Information
Student Name:
Student Birthdate:	//
Parent Name:
Address:
City:
Zip Code:
Your Phone:
Your E-Mail:
Your Child's School:
Medical Information
Please list any allergies including food, medications, etc.
Is the student currently taking medication?	Yes No
If so what?
Note any medical problems:
Please list any special dietary needs:
Emergency Contact Name:
Emergency Contact Phone:

Age Group & Uniform Size
Genin - Age 5 & 6	Uniform Size 000, 00
Chunin - Age 7 & 8	Uniform Size 00, 0
Jonin - Age 9 & 10	Uniform Size 0, 1
Kage - Age 11 & 12	Uniform Size 1, 2, 3
By submitting this form, the student(s) and/or parent or legal guardian acknowledges the existence of certain inherent risks in this type of training and hereby agrees to assume all risks himself. He further relieves Leadership Martial Arts, its management, assigned or contracted instructors and his fellow students from any liability resulting from personal injury and/or loss of personal property. The participant must have medical insurance. The student acknowledges rules and regulations governing the institute have been adopted and may be changed from time to time, and the student agrees to abide by all such rules and regulations adopted, including the time scheduled for instruction and use of the studio as posted. Children with severe behavioral issues interfering with the activities of other campers will be sent home. Parents must arrange for immediate pick up. Management has the right to refuse admission to individuals with prior behavioral issues. Occasional photos or videos of class or special events may be taken. Such materials may be used as advertising media. By submitting this form, claim to all model rights whether active or passive are waived. By submitting this form I give permission for my child/charge to be transported in a motor vehicle driven by a leadership Martial Arts staff or adult. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I recognize the risks associated with motor vehicle transportation and assume any and all expenses that may be incurred in the event of an accident, illness, or other incapacity. As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Leadership Martial Arts, its members, officers, employees, and volunteers from any claim that I might have myself or that I could bring on my child's behalf with regard to damages, demands, or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. By submitting this form, the participant(s) or parent/legal guardian of the above participant(s) give consent for medical emergency care prescribed by a duly licensed Doctor of Medicine, Dentistry, or Emergency Personnel in the event of accident or injury. This can be given under whatever conditions necessary to preserve the life, limb or well-being of the participant(s). I also agree to keep my emergency contact information updated and current.