Portland Center: 2904 SE Belmont St., Portland, OR 97214 / (503) 736-9634
STUDENT’S NAME:_________________________AGE____ DATE OF BIRTH____________
ADDRESS:________________________________CITY_________________ZIP___________
TELEPHONE (Day)______________________ (Evening)____________________________
E-MAIL ADDRESS:____________________________________
HEIGHT______________ WEIGHT____________________
EMPLOYER/SCHOOL:______________________________________________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:______________________PHONE__________
DOCTOR:___________________________________________________PHONE__________
RESTRICTIONS:______________________________________________________________
HOW DID YOU FIND OUT ABOUT US?
___Friend ___Saw our sign ___Yellow Pages ___Newspaper/magazine
ad
___Flyer/poster ___Internet Web site
___Other (please specify)_________________
WHAT REASONS HAVE PROMPTED YOU TO STUDY TAEKWON-DO?
___Self defense ___Self discipline ___Physical fitness
___Stress relief ___Family acitvity ___It seems to be fun
___Other (please specify)__________________________________________________
WAIVER: I recognize the risks of illness and injury in an exercise program and am participating in the School of Traditional Taekwon-do’s program upon the express agreeement and understanding that I am hereby waiving and releasing the School of Traditional Taekwon-do, its officers, directors, instructors, other employees and students from any and all claims, costs, liabilities, expenses or judgments, including attorney’s fees and cour costs (herein collectively “claims”) arising out of my participation in the School’s programs or any illness resulting therefrom, including acts and omissions caused by, among other things, negligence, and hereby agree to indemnify and hold harmless the School of Traditional Taekwon-do from and against any such claims.
SIGNATURE_________________________________________________DATE___________
PARENT/GUARDIAN’S SIGNATURE (if a minor)
____________________________________________________________DATE___________
PARENT/GUARDIAN’S NAME (please print):________________________________________