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I, the undersigned, hereby waive all claims against all persons connected with Shaw Martial Arts, NATF or Islamic Center of Irving for any injuries that I may sustain as a result or indirect result, of or during my participation in Karate class. I also assume full responsibility for any of my actions during class and in connection with what I have learned in class. I further agree that any pictures taken of or by me in connection with said school can be used by the school directors for publicity or promotion without compensation at this time or any other time.

First Student's Name

First Name*

Last Name*
First Student's Date of Birth*
First Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
First Student's Signature*
Second Student's Name

First Name*

Last Name*
Second Student's Date of Birth*
Second Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Third Student's Name

First Name*

Last Name*
Third Student's Date of Birth*
Third Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Fourth Student's Name

First Name*

Last Name*
Fourth Student's Date of Birth*
Fourth Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Fifth Student's Name

First Name*

Last Name*
Fifth Student's Date of Birth*
Fifth Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Sixth Student's Name

First Name*

Last Name*
Sixth Student's Date of Birth*
Sixth Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Seventh Student's Name

First Name*

Last Name*
Seventh Student's Date of Birth*
Seventh Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Eighth Student's Name

First Name*

Last Name*
Eighth Student's Date of Birth*
Eighth Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Ninth Student's Name

First Name*

Last Name*
Ninth Student's Date of Birth*
Ninth Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Tenth Student's Name

First Name*

Last Name*
Tenth Student's Date of Birth*
Tenth Student's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
Student's 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*
Phone Number
For those who join the program
Would you like to be added to our WhatsApp group?*
Yes
No
Additional information
How did you find out about Shaw Martial Arts?*
Internet / Google search
Friend / Word of Mouth
Flyer / Brochure / Ad
Other

Is there anything else you would like us to know?
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*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Any Type of Medical Conditions?
Program(s) interested in (can leave blank if not sure):
Dragons (Ages 4-6)
Fitness & Karate (Ages 4 and older)
Ninjas (Ages 6 and older)
ICI (Ages 6 and older)
Women's Only (Females ages 13 and older)
Previous years of Martial Arts experience
Do you have any of the following concerns? (Please select all that apply)
Behavior / Discipline
Being Bullied
Coordination
Health
Some other concern
No concerns

What are you / they hoping to get our of being in this program?
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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