Registration Form

August 10th - 11th

Please fill the form complitly. Sensei Sal will use this form to register you fully

Cost $125 (Payment will be processed on youir credit card

Registration form

Text me if you have questions

760-815-1254

shorinkansandiego@gmail.com

Social Media

Date

NAME (FIRST AND LAST) Regester #1

Belt color #1

Ages of #1

NAME (FIRST AND LAST) Register #2

Belt Color

Age of #2

NAME (FIRST AND LAST) Register #3

Belt Colot #3

Age Of #3

NAME (FIRST AND LAST) Register #4

Belt Colot #4

Age Of #4

PARENTS (FIRST AND LAST NAME)

Cell Phone

ANY MESSAGES FOR SENSEI SAL

Street Address

City

Region/State/Province

Postal / Zip code

VISA / MASTER CARD ONLY

EXP

CVC Code

HOLD HARMLESS AGREEMENT. I, the undersigned parent/guardian having legal custody/guardianship of the above said minor(s), give permission for the minor(s) to participate in all Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego club programs and any other affiliations. The Minor/Adult is physically able and mentally prepared to participate in all activities as described in the announcement for the program. In consideration of said Minor/Adult being permitted in any Cirincione's Inc./Karate Kids in America/Shorinkan San Diego activity for observation, use of facilities and/or equipment, or participation of the above in any program. I, on behalf of myself (as parent, guardian, coach, aide, spectator, or participant) hereby acknowledge that :(i) I have read this document, (ii) I have inspected the facilities and equipment, (iii) I accept them as being safe and reasonably suited for the purpose intended and (iv) I voluntarily sign this document. I release Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego and/or its directors, officers, employees, volunteers and any affiliates (collectively “Cirincione's Inc.”) from all liability to me for any loss or damage to property, injury, or death to person, whether caused by Cirincione's Inc. or otherwise and while such minor/adult is in or near any Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego activity or branch. I agree not to sue Cirincione’s Inc. for any loss, damage, injury, or death described above and I will indemnify and hold harmless Cirincione’s Inc. and each affiliate from any loss, liability, damage or cost they may incur due to said minor’s/adult presence in, upon or near any Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego clubs activity or branch; whether caused by the negligence of Cirincione’s Inc. or otherwise. I assume full responsibility for and risk of, bodily injury, death or property damage due to the negligence of Cirincione’s Inc. or otherwise. I do hereby authorize Cirincione's Inc./Karate Kids in America/Shorinkan San Diego clubs as agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, surgical procedure, unspecified medical treatment, and/or hospital care which is deemed advisable. The medical care is to be rendered under general or special supervision of, any physician and/or surgeon licensed under the provisions of the California Medical Practice Act. I understand that Cirincione’s Inc./Karate Kids in America/Shorinkan San Diego club programs and any other affiliate is not responsible for cost incurred for medical, surgical or dental care. I intend this document to be as broad and inclusive as is permitted by the laws of the State of California: if any portion hereof is held invalid, I agree the Release Form shall continue in full force and remain effective....................................... I agree to the terms & conditions

I Understand that my Credit Card will be charge.

Your Signature