Email
*
Phone
*
(###)
###
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Member Status
*
Current
New
Contact Name
*
First Name
Last Name
Relationship
*
Contact Name #2
First Name
Last Name
Relationship #2
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Message
*
Email #2
Phone #2
(###)
###
####
Home Phone
(###)
###
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Student's Name #1
*
First Name
Last Name
Student's Birthdate #1
*
MM
DD
YYYY
Choose a Class
*
How many days per week will you attend?
*
Any Medical and/or Physical Concerns?
Student's Name #2
First Name
Last Name
Student's Birthdate #2
MM
DD
YYYY
Choose a Class
How many days per week will you attend?
Any Medical and/or Physical Concerns?
Student's Name #3
First Name
Last Name
Student's Birthdate #3
MM
DD
YYYY
Choose a Class
How many days will you attend?
Any Medical and/or Physical Concerns?
Student's Name #4
First Name
Last Name
Student's Birthdate #4
MM
DD
YYYY
Choose a Class
How many days will you attend?
Any Medical and/or Physical Concerns?
Once you have submitted this form, payments can be made easily via: https://www.vanguardkarate.club. https://www.paypal.me/VanguardKarate or in person via card, cash, check or money order. If you have any questions, please contact Sensei Gary at vanguardkarate@gmail.com or 919-616-9899. I look forward to seeing you.
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Release of Liability - As the legal parent or guardian, I release and hold harmless Vanguard Karate, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage or injury.
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Medical Emergency - The undersigned gives permission to Vanguard Karate, its owners and operators to seek medical treatment for the participants in the event they are not able to reach a parent or guardian.
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Physical/Mental Concerns - I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health.
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Photo Waiver – I am aware that pictures of my child may be taken at Vanguard Karate. I am aware that pictures maybe posted on the web.
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