Student Name *

First Name

Last Name

Student Phone

Your phone number is required for last minute scheduling changes, or emergencies

(###)

###

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Student Date of Birth *

Please note date format DD/mm/YYYY

MM

DD

YYYY

Parent Name

Parent Details if student is under 18

First Name

Last Name

Parent Phone

Your phone number is required for last minute scheduling changes, or emergencies

(###)

###

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Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Class Subscription *

Please check the class(es) you are signing up for. You may choose more than one option.

Tuesday Age 5-7 (4:30-5:15pm)

Tuesday Age 8-12 (5:30-6:30pm)

Thursday Age 5-7 (4:30-5:15pm)

Thursday Age 8-12 (5:30-6:30pm)

Are you prescribed or taking any medication that may impair reaction time or judgement? *

Yes

No

Have you suffered any incapacity requiring medical attention in the last 12 months? *

Yes

No

Are you aware of any health problems that you have that, in the interests of your safety, the dojo/club should be advised of? *

Yes

No

Do you suffer from asthma or are you anaphylactic? *

**Asthma sufferers are required to bring their medication with them to ALL training sessions. Students should inform their instructors before training about their condition**

Yes

No

Have you studied a Martial Art before? *

Yes

No

Has a medical practitioner, or any other person or entity, or a Martial Arts club ever excluded you from martial arts in the past? *

Yes

No

*

I hereby certify and decree that all the information contained in the declaration above is true and accurate. By clicking "SEND" on this form I agree to being added to the Kyokushin Karate Colorado database and mailing list. You will not be spammed, and can unsubscribe at any point.

I give my consent

*

I fully recognise and understand that participating in martial arts in general, and Kyokushin karate in particular, can be dangerous.

I understand

*

Please click on the "Waiver" button below to review and sign our waiver. Waivers can also be signed in person at your first class.

I have signed and submitted the waiver via this site.

I will sign the waiver on-site.