Registration form 2016-17

Registration form 2016-17
Full Name: __________________________________________________________________________________________
DOB: ____________________________________________Age: _________________________
Gender: F 
Full address: _________________________________________________________________________________________
Work ph: ________________________________ Cell ph: ______________________________________
E-mail: _______________________________________________________________________ Do you give us permission to
use your email for communications and important information:
 No
Any allergies and medications:_______________________________________________________________________
Emergency contact: ___________________________________ How do we reach you: _______________________
Choose your class:
 Little Tigers (4 to 6) Wednesdays 6:30pm to 7:15pm
 Little Tigers (4 to 6) Saturdays 9:00am to 9:45am
Choose your payment:
 Membership fee:  All members $70
 Little Tigers $225  3 months
Fees are refundable with 1 month notice. Depending on the registration month some fees will be waived. Registration fee is not
refundable. Second family member will receive 10% discount.
All methods of payment accepted. Cash, cheque or credit card.
All cheques should be payable to Osuna Karate and be postdated for Oct. 1,
Jan. 1 and Apr. 1 of the corresponding year.
Total fees
GST (5%)
Total amount
Signature: ________________________________________________________ Date:____________________________
Waiver Form
I,______________________________________________________________________, parent/legal guardian of
(Name of parent/legal guardian if minor)
________________________________________________________________________ am fully aware of, and
(Name student if minor)
accept, all the risks and dangers involved in physical training. I hereby for myself, in case of injury due to training
or other activities in the space of the Calgary Waldorf School under Osuna Karate, do not hold the Calgary
Waldorf School, Osuna Karate or WSKF of Canada accountable responsible for or in consequence of any loss or
damage, however caused. I forever release, and for-ever discharge the Calgary Waldorf School, Osuna Karate
and WSKF of Canada, their servants, agents, sponsors, supporters, members, employees, or volunteers, from any
and all claims, demands, damages, actions, or cause of actions arising out of or in dangers and risks associated
with training.
Signature (Signature of parent if student is minor):___________________________Date:__________________
Parent consent for media & picture taking of a minor
Student’s name: _____________________________________________________________________________
I hereby consent to having: ___________________________________________’s_ picture appear in electronic
media and/or print publications that Osuna Karate Ltd. might choose to release. I understand that his/her picture
may be on display in accordance with any of the above-mentioned activities. I further acknowledge that my child’s
name may not be used in connection with his/her picture.
I hereby agree on behalf of the above named participant and with agreements of his/her parent or legal guardian to
waive any claims against Osuna Karate Ltd, and any staff member, which may arise from the use of any pictures
used in accordance with Osuna Karate Ltd. publications.
If at any time, I want my child’s photograph to be removed from the Osuna Karate Ltd. website or other electronic
or printed media, I acknowledge that it is my responsibility to inform, in writing, the person responsible for the
making of such material of this decision.
Parent/Legal Guardian Signature:_________________________________Date:___________________________
Karate Alberta Association
Application for Individual Membership
All first-time applicants to Karate Alberta must complete and sign this form. Print neatly. This information is used to
create your personal membership card and mailing list. Black Belts must also fill out a National Karate Association
Membership Application.
Name of Karate Club:
First Name: _____________________________________Last Name:___________________________________
City:______________________ Province:_______________________ Postal code:________________________
Home Phone:_________________________________ Work Phone:____________________________________
Email Address:_______________________________________________________________________________
 Male
 Female
Age Category:
 Adult (18 or over)
 Junior
Name of Parents or Guardians if applicant is under 18:________________________________________________
Date of Birth (mmm/dd/yy):_____________________________________________________ Age: _________________
Last Rank (dan or kyu) Attained: ______________________ Date:_______________________
I, the above named person, hereby apply for membership in the Karate Alberta Association. If this application is
accepted, I agree to abide by the Constitution, Bylaws, Rules, Regulations, Codes and Guidelines of the Karate
Alberta Association and of the National Karate Association.
Signature of Applicant
Signature of Senior Club Instructor
Privacy Note: Karate Alberta will only use your personal information for maintaining your membership and access to
our programs and the National Karate Association. Your information will not be sold or provided to other organizations.
KAA Use Only
Member Number
Date Received