KARATE | BOXING | GYMNASTICS

Hello Parents,

Please complete the enrollment and waiver form accurately and completely, as it is required for full enrollment and invoicing. Do not skip any questions.

If you have any concerns or questions, feel free to contact us anytime at: 760-815-1254

Thank you, and we look forward to welcoming your child to class! 🥋

Enrolment Info

Text me if you have questions

760-815-1254

shorinkansandiego@gmail.com

Social Media

WHY ARE YOU HERE

KARATE

BOXING

GYMNASTICS

NAME (FIRST AND LAST) DOJO CHILD 1

Birthday required

NAME (FIRST AND LAST) CHILD 2

Birthday

NAME (FIRST AND LAST) CHILD 3

Birthday

PARENTS (FIRST AND LAST NAME)

Cell Phone

ANY DISSABILITIES OR MESSAGES FOR SENSEI SAL

Street Address

City

Region/State/Province

Postal / Zip code

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, injury, 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....................................... I agree to the terms & conditions

I Understand that my Credit Card will be charge Every month. It's my Responsability to Contant Sensei Sal 5 days prior if I will not be attending class for the Month so that my Credit Card will not be charged.

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