ATA Martial Arts Student Information Sheet

Student: Last Name: ____________________________________ First : ____________________________________

Address: ________________________________________________________________________________________
Street City, State Zip

Birth-date: ______________ Age: ___________ Home Phone #: ________________Cell#_________________

If student is 18 yrs. Or older: Employer:______________________Work #:______________________

Mother's Name: _______________________________________ Wk # ____________Cell #___________

(If student is 17 yrs. Or younger – also be sure to include last name if different from student's last name.)
Father's Name: _______________________________________ Wk # _____________Cell #___________
(If student is 17 yrs. Or younger – also be sure to include last name if different from student's last name.)

Personal Reference Name: ___________________________Phone #_____________Relationship____________

Email Address: _________________________________________________________________

( For Billing Information and Upcoming Events and Announcements!!)
_________ Check Here if you DO NOT have an email address.
How did you hear about us? ______________________________________________________________________
(If you were referred here by someone, please give us their name.)

Additional Family Members Joining ATA Classes:

Name: __________________________________ Birthdate:______________ Age: _____________________

Name: __________________________________ Birthdate: ______________Age: _____________________

Liability Release & Waiver Agreement

I, the undersigned (or my parents or legal guardian, if I am a minor) have voluntarily submitted my application for registration as
a student in the ATA (American Taekwondo Association) Program. By submitting my application for membership, I do hereby
certify that I am fully aware of and understand the inherent dangers in participating in activities involving taekwondo and other
martial arts, and of the basic safety rules and procedures, including, but not limited to promotional rank testing, sparring, camps,
tournaments, and clinics which I may attend.

I understand and agree that the operators of the ATA Martial Arts, the American Taekwondo Association, its' owners, the
instructors, any other student, or agents will not be responsible for my safety, now will any of these parties or individual serve as
guardian of my safety. I also agree that I will not hold the owner of the building responsible for my safety unless injury occurs due
to faulty building structure incidents.

I understand and agree that in consideration of my being allowed to participate in taekwondo training, I hereby personally
assume any and all risks involved in connection with said training, Furthermore, I release forever the instructors and students of
the ATA Martial Arts, the American Taekwondo Association, their agents or assigns, and any other individual or entity associated
with this program, from liability, whether for-seen or unforeseen, arising our of my participation in Taekwondo events or
activities, including any harm, injury, or damage that may occur to me or befall me, my family, descendants, heirs, or assigns with
practicing or performing Taekwondo at any time or place, or while traveling to and/or from any Taekwondo related events or
activities.

I state that I am of lawful age and legally competent to sign this agreement and that my signing this agreement is my own free act
(unless signed by parent or legal guardian). I understand and agree that the terms herein are contract, and that they are not mere
recital or simply for information purposes.

I have read, understand, and fully informed myself of the contents of this agreement. I assume sole responsibility for my physical
condition and capability to perform under the program, promotional rank testing, tournaments, camps, or clinics in which I may
participate.
Student Signature or Parent/Legal Guardian (if student is under 18 yrs. Of age.):

X ___________________________________________________________________
Past injuries, illnesses, or special information: _____________________________________________________________________

Date _______________Intro Special Dates: From ___________ to ___________ Amount Pd:____________

Amount Paid $ ____________ Cash Credit Card Money /Order Check#