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Please fill out this waiver and then you can get started with your free week!

 

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Please read the following waiver to begin.

  • That entering the facilities of Pooler Karate and participating in all Activities within it (including but not limited to martial arts or self-defense training, lessons or classes, competitions, events, exercise, and callisthenic activities) may expose him or her, or the child, to many inherent risks including accidents, bodily injury (including serious bodily injury and death ), and illness.
  • Pooler Karate urges all Guests or Members, of all ages, to obtain a physical examination prior to attendance in any Activity. It is the responsibility of the person signing below to communicate any physical and physiological concerns that might conflict with their participation, or their minor’s participation, in any Activity. The person signing below declares that they, or the participating minor, are physically fit, mentally capable and suffering from no condition, impairment, disease, infirmity, or illness that prevents participation in any activity or use of the premises or equipment of Pooler Karate.
  • In recognition of the possible dangers  or risks connected with any physical activity, the Guest or Member hereby knowingly and voluntarily waives any and all claims (including all costs and expenses), indemnifies, and releases from liability Pooler Karate and Pooler Karate’s Instructors, agents, and employees from any and all injuries or harms arising as the result of use of the facilities or property of Pooler Karate—including any bodily and personal injuries or damages to property that arise from participation in any Activity.
  • I understand and agree to all terms and policies of Pooler Karate.
     

 

I Agree

Your signature will be required in the next step.

First Members Name

First Name*

Middle Name

Last Name*

Phone*
First Members Date of Birth*
First Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
First Members Signature*
Second Members Name

First Name*

Middle Name

Last Name*
Second Members Date of Birth*
Second Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Third Members Name

First Name*

Middle Name

Last Name*
Third Members Date of Birth*
Third Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Fourth Members Name

First Name*

Middle Name

Last Name*
Fourth Members Date of Birth*
Fourth Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Fifth Members Name

First Name*

Middle Name

Last Name*
Fifth Members Date of Birth*
Fifth Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Sixth Members Name

First Name*

Middle Name

Last Name*
Sixth Members Date of Birth*
Sixth Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Seventh Members Name

First Name*

Middle Name

Last Name*
Seventh Members Date of Birth*
Seventh Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Eighth Members Name

First Name*

Middle Name

Last Name*
Eighth Members Date of Birth*
Eighth Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Ninth Members Name

First Name*

Middle Name

Last Name*
Ninth Members Date of Birth*
Ninth Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Tenth Members Name

First Name*

Middle Name

Last Name*
Tenth Members Date of Birth*
Tenth Members Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Members Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Area of Interest
Is there any specific program you're interested in? Feel free to select more than one. Or if you're not sure, select "I'm not sure!"*
Karate
Lil' Ninjas
Krav Maga
Brazilian Jiu-Jitsu
Lil' Rollers
Homeschool
I'm not sure!
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Other Information
Do you have any medical issues that we should be concerned about?*
No
Yes

If yes, please enter it here.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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