Martial Arts

Sponsored by: ATEDY, INC

Date: Month/Day/Year

 

 

 

Watson School for Men of Wu Kung

5702 S. Racine Ave.

Chicago, IL 60636

773.527.8856    773.321.6441

 

Student Application

 

Name ___________________________________________________________________________

Address ________________________________________________________________________

City, State, Zip code __________________________________________________________

Home Phone #_________________________________

Emergency Phone # ___________________________ Contact Name _____________________

 

Student’s First & Last Name

Birthday

Program

Fee

Staff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payment Cash  Check  Check#

 

 

Total

 

 

Please list any prior Martial Arts Experience:__________________________________ ________________________________________________________________________________

 

Please list any special-needs of the student(s):________________________________ ________________________________________________________________________________

WAIVER RELEASE FORM

 

I recognize and acknowledge that as I and/or my child participate in this program, there are certain risks of physical injury, and I assume full risk of any injuries including death, damages or loss, which I and/or my child sustain as a result in participating in any and all activities, connected

with or associated with such program.

 

I agree to relinquish all claims I and/or my child have as a result of participating in the program, against the School and Its officers, Agents, Employees and Sponsor ATEDY, Inc..

 

I do hereby fully release and discharge the Watson School for Men of Wu Kung /ATEDY, Inc. and its Officers, Agents and Employees from any and all claims from injuries, including death, damage or loss which I and/or my child may have or which May accrue to me and/or my child on account of my and or my child’s participation in the program.

 

I further agree to indemnify or hold harmless and defend Watson School for Men of Wu Kung / ATEDY, Inc. and its Officers, Agents and Employees from any and all claims resulting from injuries, including death, damages and losses sustained by me and/or my child arising out of, connected with, or in any way associated with the activities of the program.

 

____________________________________________    ________________________________ 

Waiver Release – Signature                      Print Name

(Parent or Guardian if under 18)   A Signed Waiver Release form is required for each student at Watson School for Men of Wu Kung.   ***NO EXCEPTION***

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