Sign up and waiver form

Shisenkan Tenyo Dojo

Waiver and application form

By filling out and signing the below document i agree to the the following:

a) I understand martial arts can be dangerous

b) I will follow all instructions given to me by the teachers

c) I acknowledge that at this time i may not be covered by insurance

d) I will not sue or make any claim against the instructors or other students

e) I will not take photos/videos of anything in the Dojo without permission

f) I will not use/teach any technique except in a real emergency

1. Student Details:

First name*

Last name*

Date of Birth*

Day

Month

Year

Address

Phone number*

Email*

Emergency Contact's Name*

Emergency Contact's Relationship*

Emergency Contact's phone number*

Criminal History

Have you ever been convicted of a 'Crime of Violence;?*

Yes

If yes, please give details

Medical History

Do you suffer, or have ever suffered from any of the following?*

Heart Disorders

Nervous Disorders

Epilepsy

Migraine

Diabetes

Haemophilia

Blood Pressure

Respiratory Condition

N/a

Other

Gym Access

Our facilities include an un-manned gym, this facility is open for adult students to use and contains equipment that is potentially dangerous if misused or untrained. All students must complete a safety induction before being allowed to use the gym, and use the facilities at their own risk.

I understand I am not to use the gym until I have completed a safety induction

I understand I use the gym facilities at my own risk

Signature

I declare that the info I’ve provided is accurate and complete.

Signature*

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Name of Student (or guardian) signing*

Tenyo Dojo has a WhatsApp group for parents & students where we post information, updates and changes, if you do no wish to be added to this group please tick the box below and provide us with an alternative preferred contact method.

I do not wish to be added to and receive information via the WhatsApp group

For more information see Shisenkan Honbu Website www.shisenkan.org

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