Ana səhifə

White lotus kung fu system please print membership no


Yüklə 17.67 Kb.
tarix22.06.2016
ölçüsü17.67 Kb.
WHITE LOTUS KUNG FU SYSTEM

PLEASE PRINT MEMBERSHIP NO: __________

NAME: (Last) (First) (Middle)


Address: City: State: Zip:

Date of Birth: / / Age: Height: Weight: Marital Status: Married Single

Home Ph.: ( ) - Cell: ( ) - Email:

Occupation: Business Ph.: ( ) -

Your present general health:

Recent operation: When: Purpose:

Any chronic ailments: Limitation(s):

Any problems we should be aware of:

How was the studio chosen: Internet Magazine Phone Ad Walk by Other:

Referral: Person's name: Other:

Any previous training: When: Style(s)

Instructor(s): Where:

In Case of Emergency Contact: (Relationship) Phone: Cell:

( ) - ( ) -



The student specifically agrees and fully understands that White Lotus Martial Arts Center, LLC will not be liable for any damages arising from personal injuries sustained by Student and fully assumes responsibility for any injuries or damages which may occur to him/her in or about the premises of said Center. The Student in attending said Center and using the facilities and equipment therein specifically understands that he/she does so at his/her own risk. I hereby fully and forever release and discharge White Lotus Martial Arts Center, LLC, it’s officers, shareholders, directors, employees and agents from any and all claims, demands, damages, rights of action, or causes of unanticipated, results from or arising out of Student's use or intended use of said Center or the facilities and equipment thereof. This release including but not limited to, any claims for personal injuries resulting from or arising out of negligence of any other person present on the premises of said Center including other persons using said Center as Students.

The information supplied by you is correct to the best of your knowledge.

I have read all the foregoing and am fully aware of the legal consequences of signing this document.


SIGNATURE: DATE: _______________

PARENT OR GUARDIAN SIGNATURE: DATE: _______________

(under 18 years old)

I agree to pay the full amount of $ per month OR $ per hour for privates lessons

DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY

Start Date: / /

PROGRAM(S):

Restart: / /

DAYS: M TU W TH F S

Time(s):

Original Start: / /

PANTS: S M L XL

SHIRT: S M L XL

Sash Given:

CK#

$

CA

$

DISCOVER

MC

VISA

.


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©kagiz.org 2016
rəhbərliyinə müraciət