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Registration Form

REGISTRATION FORM
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GOLDSTREAM AVENUE TAE KWON DO ACADEMY

1096A Goldstream Ave.,
Langford, B.C. V9B 2Y5

Ph. 250-391-6255

REGISTRATION FORM DATE:____________________

Last Name__________________________________________ First Name ________________________________________

Male _____ Female ____ Birth Date _____________________Medical Number ____________________________________

(Day/Month/Year)

Father’s Name _______________________________________   Mother’s Name___________________________________

Address __________________________________ City ____________________________      P/C ____________________

Home Phone ____________________   Email ________________ Cell _______________________

Emergency Contact/ Phone ___________________________

Have you ever taken martial arts before? ____    Current physical activities _______________________________________

Physical/ Medical Challenges ____________________________________________________________________________

PAYMENT CONTRACT

The monthly fee is $_________due on the __________of each month for _____ months. The first month’s fee is due with
the registration. If _____ months are paid for in advance on the date of registration a discount of 10% will be applied at the
time of payment.

Cancellation Policy

This contract may be cancelled within the first 72 hours of signing. The academy or student may cancel the contract with
written notification and with GOOD reason (I.e. failure to comply rules & policies of the academy; moving out of area; health
problems; notification etc.).

I / we ______________________ (student/parent/guardian) are aware of the commitment involved in martial arts training (as explained) and agree to it.

Student Signature__________________________________ Parent/Guardian Signature______________________________

PHOTO RELEASE

I/ we___________________ agree to having my picture taken and the photo/ video image becomes the property of Goldstream
AvenueTae Kwon Do Academy. I further give permission for this to be used in advertising, brochures, or other forms of media
that the Sabomnin ofGoldstream Tae Kwon Do Academy chooses to use them for.

Student Signature____________________________      Parent/ Guardian Signature___________________

RELEASE AND WAIVER OF LIABILITY

We, the student & guarantor, if applicable, on behalf of ourselves, members of our family, our heirs, executors, administrators
and assigns, hereby forever release, discharge and hold harmless, Goldstream  Avenue Tae Kwon Do Academy,
representatives, agents, and landlord for any injury, loss, or damage to my person or property how so ever caused, arising out
of or in connection with my taking part in martial arts classes and activities and not withstanding that the same may have
been contributed to or occasioned by the negligence of Goldstream AvenueTae Kwon Do Academy representatives or agents.
Please note: participants must supply their own protective equipment.

In the event of an emergency, the student/parents/guardian give permission for emergency first aid to be administered or
emergency medical help be called by the representatives of Goldstream Avenue Tae Kwon Do Academy, only 1st Aid will be
administered and the student/parents/guardians will hold Goldstream Avenue Tae Kwon Do Academy harmless for any
consequences of first aid and will assume the costs of such treatment. Reasonable attempts will be made to contact the
parent/guardian/emergency contact, in the event of failure to do so the student/parent/guardian give permission for Goldstream
Avenue Tae Kwon Do Academy to act on their behalf in the case of an
emergency for the best medical interest of the student.

I____________________ agree to abide by the rules & safety regulations of Goldstream Avenue Tae Kwon Do Academy.

Student Signature__________________________________ Parent/Guardian Signature_____________________________

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