Name

First Name

Last Name

DOB

YYYY

Age

Sex

Male/Female

Parent/Guardian Name

Parent/Guardian is required if registering a child

Parent/Guardian Number

(###)

###

####

Address

Full Address

Emergency Contact

Name/Number

Other/Limitations

Asthma, ADHD, Pregnancy, Allergies, All Past Injury / Health Concerns and any other physical limitations that we should be aware of.

RELEASE

By signing this form, I waive any and all claims for myself and or my child against Myloreal’s Martial Arts Academy L.L.C., Mikio Surai Martial Arts, Myloreal Anderson, the facility at which this program is held and Myloreal’s Martial Arts Academy L.L.C. staff members for loss or damage to personal items or injury that may result directly or indirectly from participation in this activity. Myloreal’s Martial Arts Academy L.L.C. has my permission to photograph/video myself and or my child for promotional and educational purposes.

Signature

MUST HAVE WAIVER SIGNED TO PARTICIPATE. This will serve as your electronic signature.

Date

YYYY

Seminars