Please print out this application and fill it out by hand, in print, with either
black or blue ink. Once you have completed this application you may mail it to
our school, or you can return it to us in person at the following address: 4724
W., Lovers Lane, Dallas, TX 75209.
 Application for student enrollment in Martial Arts
Admission fee: $20.00 All promotion examination fees are
extra.
Personal Information
Driver's License Number _____________________ Social Security Number
_________________________
Name _____________________________________________________ Age
_________ Sex _________
Current Address _____________________________________ City
__________ State ____ Zip _______
Work Address ______________________________________ City
__________ State ____ Zip _______
E-Mail Address _____________________________________
Telephone-Home ____________________________ Telephone-Work
____________________________
Date of Birth __________________________ Height ________ Weight
_________ [] Married [] Single
Citizen of U.S.A. [] Yes [] No Occupation
__________________________________________________
Referred By
__________________________________________________________________________
Physical Record
List any physical defects
_________________________________________________________________
____________________________________________________________________________________
What foreign languages can you speak fluently?
________________________________________________
___________________________________ [] Read [] Write
All classes, practice sessions, and contests
conducted by your instructor or master are supervised with
reasonable care taken to prevent any injury and to minimize
accidents. However, because of the strenuous nature of Martial Arts
and combative activities, no one can positively assure the student,
member, or instructor that injury will not result during practice
sessions, instructional periods, and contests.
THEREFORE I, the above mentioned student, do hereby for
myself, my heirs, executors, administrators, and assigns waive, release, and
forever discharge any and all rights and claims whatsoever for damages which I
may have, or shall hereinafter accrue to me, against my instructor, master, or
to other members, for any and all damages which may be sustained and suffered by
me in connection with my association or entry in any practice, class, contest,
or athletic events, or which may arise out of my traveling to, participating in,
or returning from such endeavor.
Student agrees to keep and obey all rules and regulations now
in force or in the future prescribed by the Martial Art or its associated
martial arts, for the use of martial arts and the equipment and facilities
therein including rules with respect to lockers, uniforms, and personal hygiene
and the Martial Art reserves the right to revoke this membership if student
fails to keep and obey any of such rules and regulation or for reasons of
nuisance, disturbance of other students, moral turpitude, or fraud. Positively
No Refunds on any amount paid for registration fee, tuition fee, uniforms, or
any other deposits made.
Student Signature _________________________________________ Date
________________________
Parent/Guardian Signature ___________________________________ Date
_______________________
Authorized Signature _______________________________________ Date
_______________________
======================Applicants: Do not write below this line.=======================
Type of Martial Arts ______________________________________________
Schedule of Payment ______________________________________________
Enrolled for _____________________________ Program _____________
Class __________________
Chapter Code ______________________ Student's I.D. Number
_______________________________
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