Adult Registration Form

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

Other: _____________________________________________________

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).


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 __________________________________________________________________________________

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