Pacific Northwest Martial Arts Academy (PNMAA LLC) Registration & Liability Release Form
Mother (First/Last) ________________________________________________
Father (First/Last) _________________________________________________
(Complete Mother/Father info if student is less than 18 years of age)
Mailing Address ____________________________ City _______________ State ____ Zip ____________
Home Phone _____________ Mother’s Cell Phone ______________ Father’s Cell Phone_____________
Email Address ___________________ Emergency Contact___________________ Phone _____________
Student’s Name (First/Last) __________________________ Date of birth ___________ Gender: M F
1st Class Name ___________________ Day of week ______________ Time _________________
2nd Class Name ___________________ Day of week ______________ Time ________________
2nd Student’s Name (First/Last) _______________________ Date of birth ___________ Gender: M F
1st Class Name ___________________ Day of week ______________ Time ________________
2nd Class Name ___________________ Day of week ______________Time ________________
Registration Fee: $35.00 per student or $50 per family (Required and good for 1 full year).
Payment Information: We currently accept cash & checks payable to PNMAA. A $55 returned check charge will be added for any checks returned by the bank. Punch card tuition payment is due upon purchase. Accounts not paid by the 10th of the month will be subject to a $10 late fee.
LIABILITY, MEDICAL & CONSENT RELEASE / PAYMENT AGREEMENT
Release of Liability / Parent Consent
As the legal parent or guardian, 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 Emergence 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 they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or conditions and/or declare the participant to be in good physical health and mental health.
Current Health Issues ___________________________________________
I request that our doctor ________________________ be called and that my child be transported to _____________________ hospital. Please include doctor’s phone number ____________________
Printed Name of Parent/Guardian ___________________________________ Date ______________
Parent Signature ____________________________________________________________________