Shaolin Martial Arts Center
2631C Bridgeway ∙ Sausalito, CA 94965 ∙ ( 415.331.8838 ∙ 6 415.331.8878
Application for: Tai Chi r Kung Fu r Chi Kung r
Name: __________________________________________________________________________________ Male r Female r
Last First M.I.
Address:________________________________ City _________________ State _______ Zip ___________ Single r Married r
Phone: (Home) ____________________ (Cell) ____________________ E-Mail ___________________@______________________
Birth date: _____________________________ Birthplace ____________________________________
Education: __________________________________________ Social Security#_________/_______/__________
Employer: ________________________________ Occupation __________________________ Phone ________________________
Martial Arts Background: Style __________________________ Rank ________________________
Years of Training ______ Instructor _______________________ Location _____________________
Referral: Friend r Yellow Pages r Web Site r Other: ________________________________
I, the undersigned, do hereby voluntarily submit my application for admission to The Shaolin Martial Arts Center for attendance and participation in lessons at Shaolin Martial Arts Center. Furthermore, I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, if any, while participating in any activity at or for Shaolin Martial Arts Center. Furthermore, I do hereby waive all claims against the instructors and/or fellow students of said classes, and the owner of the building, for any injuries which I may sustain in the course of activities at or for Shaolin Martial Arts Center. Furthermore, I voluntarily consent that any picture furnished by me or any pictures taken of me in connection with Shaolin Martial Arts Center may be used for publicity and/or promotion of same. Furthermore, I waive the right to any compensation in regard thereto. I understand that there are NO REFUNDS for any fees or tuition paid by me for the classes at Shaolin Martial Arts Center, unless the classes or courses in which I am involved are discontinued. I also realize that I am responsible for payment in a regular and timely manner.
Signature of Applicant______________________________________________________ Date: __________________
If applicant is under eighteen years of age, this release and consent must be signed by a parent or legal guardian.
Signature of Parent/Guardian:________________________________________________ Date: ___________________