Pacific Northwest Martial Arts Academy (PNMAA)
Registration & Liability Release Form—Adult (18 & up)
Adult Student Name (First/Last) ______________________________ Date of Birth: ___________________
Email Address ____________________________________________________________ Gender: M F
Mailing Address ___________________________ City _________________ State ___ Zip ______________
Home Phone _____________________________ Cell Phone ______________________________________
Emergency Contact Name ____________________________ Emergency Contact Phone ________________
Program: Kung Fu/Wushu Taichi Self-Defense Basics
Class Day(s) of Week _______________________________ Class Time(s) ____________________________
Registration Fee (required & good for 1 full year): $35.00 per student or $50 per family (immediate family)
Payment Information: We currently accept cash and checks payable to PNMAA. Credit card payments are accepted as well (on-line via Square). A $55 returned check charge will be added for any checks returned by the bank. Payment, in full, is due upon purchase of Class Punch Cards (one Punch Card per person, non-transferrable and non-refundable).
LIABILITY, MEDICAL & CONSENT RELEASE / PAYMENT AGREEMENT
Release of Liability
I release and hold harmless Pacific Northwest Martial Arts Academy (PNMAA LLC), its owners and operators, from any and all liability, claims, demands, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises under the control and supervision of Pacific Northwest Martial Arts Academy (PNMAA LLC), its owners and operators or in route to and from any said premises.
Medical Emergency Release
The undersigned gives permission to Pacific Northwest Martial Arts Academy (PNMAA LLC), its owners and operators, to seek medical treatment for the participant in the event the participant is not able to clearly perform this function on their own. I hereby declare any physical/mental problems, restrictions, or conditions and/or declare the participant to be in good physical and mental health.
Health issues PNMAA should know about (injuries, allergies, etc): __________________________________________
I have read and agree to the aforementioned payment conditions and releases:
Signature ________________________________________________________ Date ________________________
Printed Name __________________________________________________________________________________