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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.

Pooler Karate urges all members to obtain a physical examination prior to attendance in any classes, activities or events. In recognition of the possible danger connected with any physical activity member hereby knowingly and voluntarily waives any right of cause of action of any kind whatsoever arising as the result of such activity from which any liability may or could accrue to Pooler Karate, Instructors, agents, and employees. I understand and agree to the 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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
In order to help us best serve your needs please check the areas that need improvement
Please select all options that apply.
Discipline
Coordination
Respect
Self Control
Self Esteem
Assertiveness
Self Defense
Attention
Fitness
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.
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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