Hebron School of Karate

*First Name

*Last Name

*Email Address

*Phone Number

*Address Line 1

Address Line 2

*City

*State/Province/Region

*Zip/Postal Code

*Student's Date of Birth:

*Is student under the age of 18?:

*Mother's Name:

Mother's Cell Phone (if different from above):

Father's Name:

Father's Cell Phone (if different from above):

*Where do you attend Church?:

*Does student have any medical issues we should be aware of?:

*Insurance Provider:

*Policy Number:

*PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE AGREEMENT.

AUTHORIZATION AND RELEASE OF LIABILITY:
I am a current participant in, or registering for, myself/my child to be a student in the Hebron School of Karate (HSOK) at Hebron Baptist Church. I understand that there are certain risks associated with the sport and that various injuries are a possibility. Nonetheless, I hereby assume the risks for myself/my child associated with Karate as evidenced by my acknowledgement. Additionally, I have provided my insurance company and policy number, and will rely solely on my insurance coverage for payment of any and all medical expenses I may incur in the event of an injury. I will not seek recovery for any medical expenses I incur from Hebron Baptist Church, or any of its agents, officers, successors, or assigns. Finally, by acknowledging this statement, I hereby release Hebron Baptist Church, its agents, officers, successors, or assigns from any and all liability for personal injury, medical expenses, or any and all costs or damages incurred or suffered by myself/my child while participating in any activities with Hebron School of Karate .

I have read and agree to the information above (please type name below).

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