Martial Arts Course Registration Form

Athlete Information

Athlete's Name

First NameLast Name

Birth date

DayMonthYear

Gender

MaleFemaleOther

Current level

White belt (beginner)Coloured beltBlack beltOther

Date

Parent/Guardian Information (if athlete is under 18)

Name

First NameLast Name

Mobile Number

eg 021Phone Number

E-mail

example@example.com

Alternative Emergency Contact

Emergency Contact's Name

First NameLast Name

Mobile Number

eg 021Phone Number

Does the athlete have asthma, allergies, or any other medical condition? If yes, please describe.

Membership

Membership type

Opening offer: 3 classes and free uniform for $19.99Term pass: 10 classes a term for $100Unlimited training: Up to 3 classes a week for $19.99 per weekPersonal instruction: Price as agreed

Payment option

Cash - please make payment at beginning of classOnline payment - please request internet banking detailsDirect debit - please request direct debit form

Acknowledgement

I understand that all sports carry a risk of injury and that Mozhdeh Martial Arts is not responsible for injuries or loss suffered as the result of participating in these activities.

From time to time Mozhdeh Martial Arts will post photographs of our athletes, coaches, and supporters online. I will let Mozhdeh Martial Arts know by email if I do not consent to my or my child’s photos being shared.

Mozhdeh Martial Arts will give 30 days written notice of any fee increase.

Medical Authorization

In the event of an injury or medical emergency, I allow Mozhdeh Martial Arts to provide first aid, arrange transport to a medical facility, and authorise emergency treatment as recommended by a doctor for the athlete named above.

I understand that all reasonable efforts will be made to contact the athlete’s parent and/or emergency contact if an injury or medical emergency occurs.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Mozhdeh Martial Arts Registration

Membership