Boy's And Girl's Club Enrollment

Please complete the intake and waiver, accurately and completely, as it will be used for the enrollment to the Boy's and Girl's Club Karate program. Please do not skip any questions, and feel free to contact us if you have any concerns or questions 760-815-1254.

This is a free program that will be tought by internationls certafied instructors. All karate students will progress through the colored karate belts. The Karate Unifrom is NOT madatori. How ever it will motivate them when doing karate. Please contact us if you wish to purchase one for $40. (760-815-1254)

Open to all Club members

Wednesday @ 5: PM

410 W California ave,

Vista, Ca, 92083

If you wish to pourchase the unifrom quicker, please come to the main site down the road from the club. You can pauy at the main site.

1234 N Santa Fe Ave,

Vista, CA, 92083

760-815-1254

(call to set up)

Date required

NAME (FIRST AND LAST) BGCV CHILD 1

GRADE CHILD# 1

Hight 1

NAME (FIRST AND LAST) CHILD 2

GRADE CHILD # 2

Hight 2

NAME (FIRST AND LAST) CHILD 3

GRADE CHILD #3

Hight 3

PARENTS (FIRST AND LAST NAME)

Cell Phone

ANY DISSABILITIES OR MESSAGES FOR SENSEI SAL

Street Address

City

Region/State/Province

Postal / Zip code

I accept terms & conditions (Hold Harmless Agreement I, the undersigned parent/guardian having legal custody/guardianship of the above said minor(s), give permission for the minor(s) to participate in all Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego club programs and any other affiliations. The Minor/Adult is physically able and mentally prepared to participate in all activities as described in the announcement for the program. In consideration of said Minor/Adult being permitted in any Cirincione's Inc./Karate Kids in America/Shorinkan San Diego activity for observation, use of facilities and/or equipment, or participation of the above in any program. I, on behalf of myself (as parent, guardian, coach, aide, spectator, or participant) hereby acknowledge that :(i) I have read this document, (ii) I have inspected the facilities and equipment, (iii) I accept them as being safe and reasonably suited for the purpose intended and (iv) I voluntarily sign this document. I release Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego and/or its directors, officers, employees, volunteers and any affiliates (collectively “Cirincione's Inc.”) from all liability to me for any loss or damage to property, inju ry, or death to person, whether caused by Cirincione's Inc. or otherwise and while such minor/adult is in or near any Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego activity or branch. I agree not to sue Cirincione’s Inc. for any loss, damage, injury, or death described above and I will indemnify and hold harmless Cirincione’s Inc. and each affiliate from any loss, liability, damage or cost they may incur due to said minor’s/adult presence in, upon or near any Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego clubs activity or branch; whether caused by the negligence of Cirincione’s Inc. or otherwise. I assume full responsibility for and risk of, bodily injury, death or property damage due to the negligence of Cirincione’s Inc. or otherwise. I do hereby authorize Cirincione's Inc./Karate Kids in America/Shorinkan San Diego clubs as agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, surgical procedure, unspecified medical treatment, and/or hospital care which is deemed advisable. The medical care is to be rendered under general or special supervision of, any physician and/or surgeon licensed under the provisions of the California Medical Practice Act. I understand that Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego club programs and any other affiliate is not responsible for cost incurred for medical, surgical or dental care. I intend this document to be as broad and inclusive as is permitted by the laws of the State of California: if any portion hereof is held invalid, I agree the Release Form shall continue in full force and remain effective)

PLEASE CHECK YES IF YOU WANT TO BUY A UNIFORM FOR $40. SENSEI WILL SEND YOU AN INVOICE. MAKE SURE THE HIGHTH OF YOUR CHILD IS CORRECT. Click no if you will be purchasing one at the main site. Required

YES

Cell Phone