Gambatte Karate Student Application

Student's Name
Birthdate MM/DD/YYYY
Street Address
City
Zipcode
Phone xxx-xxx-xxxx
E-Mail
Student or Parent Employer
Employer Phone xxx-xxx-xxxx
Emergency Contact Name
Emergency Contact Phone xxx-xxx-xxxx
What are your reasons and/or goals for training with Gambatte Karate?”
How did you hear about us?	Phone book Drive by Newspaper Referral Website Flyer
Do you have any medical conditions?	Yes No
Describe medical conditions

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I hereby consent to participate in activities offered by Gambatte Karate. It is hereby agreed that I or my children waive and release all rights and claims for damages that I may have at any time against the School, or it's representatives whether paid or volunteer for any injury or damages in connection with the Karate program or other activities related to GAMBATTE KARATE. The risk involved in respect to such a program is fully understood. Permission for medical treatment: I confirm that the above named person is in good health. I hereby authorize simple first aid and consent to any x-ray, exam and medical or surgical diagnosis which is deemed necessary.