Child/Family Registration Form

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

1^st Class Name ___________________ Day of week ______________ Time _________________

2^nd Class Name ___________________ Day of week ______________ Time ________________

2^nd Student’s Name (First/Last) _______________________ Date of birth ___________ Gender:   M     F

1^st Class Name ___________________ Day of week ______________ Time ________________

2^nd 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 10^th 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 ____________________________________________________________________