TAEKWON-DO REGISTRATION FORM

Semester: April to July or

July to October

Registration Fee: $60 per student

Date Fee Received: _______________ ($60 check or cash)

Uniform Size(s): _______________ ($35 check or cash)

Student’s Name: _____________________ Student’s Name: _____________________

Street Address: _____________________________________________________________

City: _________________ MD or PA Zip Code: _______________

Phone Number: _______________ e-mail: ____________________________

Age(s): __________________ Birth Date(s): ______________________________

Parent’s Name: _____________________________________________________________

Parent’s Address: ___________________________________________________________

Any other person who could be notified in case of emergency if parents are unavailable:

Name: __________________________ Phone: ____________________________

Physician: _______________________ Phone: ____________________________

Are there any medical or other health factors that might affect the participant’s ability to participate or perform in the full contact martial arts Taekwon-Do program? ________ No ________ Yes

Is the participant taking any medication that might affect his/her safety or performance in these activities? ________ No ________ Yes

(Note: If the answer to either of the above two questions is YES, a medical release may be required.)

Parents: It is necessary that you read and complete all information for the protection of your child.

I hereby approve of the terms of this registration form/contract signed by myself and my child. I further agree that I will not hold any Recreation Council, Organizers, Instructors, Sponsors, Supervisors, Volunteer Leaders or Participants responsible for injuries or any unforeseen accident while participating in the full contact martial arts Taekwon-Do program, or while traveling to or from or being transported for these activities .I hereby acknowledge that I have read and fully understand the above mentioned information. I further certify that all answers, to the best of my knowledge, are true and correct.

______________________________ _________________________________

Participant’s signature Parent’s/Guardian’s Signature