Seiken RegistrationTo register for our karate programs, please carefully fill out the following form. Student DetailsFull Name *Date of Birth *Age *Gender *Select GenderMaleFemaleParent / Guardian DetailsFull NameEmail Address *Phone *Street Address *City *Photo / Video Permission *I give permission for photos and videos to be taken during classes.YesNoEmergency Contact Name *Emergency Contact Phone *Program2 Days a Week3 Days a WeekI am currently a studentYesMedical Conditions / Allergies / MedicationsPayment DetailsUse Payment Information Previously ProvidedIf you have previously given us your payment details, please let us know if we can continue to use.YesNo, I will provide new payment detailsIf you have never supplied payment details or would like to submit new payment details, select "No" above and we will contact you to securely get your payment information.ACKNOWLEDGEMENT AND RELEASE FORMConsent *I, the applicant, on behalf of myself, members of my family, my heirs, executors, administrators and assigns, hereby forever release, discharge and hold harmless Seiken School of Martial Arts, representatives, owner, and agents for any injury, loss or damage to my person or property howsoever caused, arising out of or in connection with my taking part in Martial Art Classes, Self Defence Seminars and activities and notwithstanding that the same may have been contributed to or occasioned by the negligence of Seiken School of Martial Arts, representatives, owner, and agents. Please note: Participants must supply their own protective equipment. The undersigned acknowledges that: He/She is desirous of using, as a member on a membership basis, the Martial Arts School herein referred to as Seiken School of Martial Arts. He/She has received a completely executed copy of this agreement. He/She confirms that there were no verbal presentations other than those specified in this agreement. He/She may be photographed or filmed while attending at the premises of Seiken School of Martial Arts and he/she gives permission to Seiken School of Martial Arts and any affiliates to use any and all photos, video footage, and/or video streaming for promotional, sales, publicity, and advertising purposes for all media including internet. The waiver was read and he/she agrees to abide by it. If the student is under 19, please enter the details of the parent/guardian who will be e-signing this form.Parent/Guardian NamePhonee-SignatureBy submitting this form you are consenting to your full legal agreement to all the above terms.Submit
