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Korean Martial Arts Academy
1858 Virginia Ave. Holiday Shopping Center Martinsville, VA
(276) 632-7360 or (276) 638-6191
MEMBERSHIP APPLICATION
Business Phone: ______________________
Residence Phone: _____________________
Name: __________________________________________________________________
(LAST) (FIRST) (MIDDLE)
Address:________________________________________________________________
Date of Birth: _________________ Height: _________Weight: ________ Sex: _______
Education: ______________________________________________________________
Occupation: ___________________________ Employer: _________________________
Medical History: _________________________________________________________
_______________________________________________________________________
Reason for Interest in Korean Martial Arts: ____________________________________
I hereby make application for membership in The Korean Martial Arts Academy, and upon acceptance, I sincerely pledge to obey all the rules and regulations which are set up for the purpose of keeping the order of the academy, and for the protection of pupils from injury. I recognize that a risk is involved in this art that requires my adherence to these rules, and to the instructors discipline.
In consideration of accepting my entry into the academy and taking training from Korean Martial Arts Academy, I hereby release Martial Arts Academy’s owner, instructors, officers, employees, members, and authorized guests from all responsibilities, liabilities and claims for injuries that I may receive while being instructed in and participating Korean Martial Arts, and the parent and guardian of the applicant hereby requests that the application be accepted, and in consideration thereof agrees to accept the release f liability as herein before stated and to indemnify and hold harmless the academy, and individuals listed in the first part of the paragraph from all claims made by or on behalf of the applicant, for the aforesaid consideration.
Applicant’s Signature: _____________________________ Date: __________________
In the Presence of: ________________________________________________________ (Parent or Guardian’s Signature)
Accepted: ________________________________(Instructor)