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)
¨  By checking this box I would like to be notified of any free monthly seminars or

e-mailed regarding 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 OR what are you interested in developing with martial arts training?

 

_____________________________________________________________________________

 

PARENTS:  Please indicate lesson time(s) & day(s) you would like your child to attend regularly.

(This portion of application is for children program only)

 

 

 

 

 

 

 

 

 

 

 

 

 

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 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 all information below or on page 2 of this release form and sign in agreement.

 

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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.            
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.

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.

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.

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. 

 

 

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

 

                                 Print Name:  ____________________________________________________

 

PARENTS/GUARDIAN: Authorization if Student is a Minor

 

 

Parent’s Signature: _________________Relationship: ______________            Date: ____/____/____

 

 

                             Print Name: __________________________________

 

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