N.Y.F.K. Sport Center Registration Form Today`s Date: / / . Member

Office use only:
Entered ____________
ID#: _______________
N.Y.F.K. Sport Center
Registration Form
Today’s Date:
/
/
.
Member Information
Last Name: __________________________ First Name:___________________________________
Date of Birth (MM/DD/YY):
/
/
.
Address: __________________________City________________State__________Zip ___________
Home Phone: ________________________ Cell: _______________________
Email: _______________________[email protected]___________________
Uniform Size ( * all members are required to purchase uniform: $___________ )
Child :
S
M
L
Adult :
S
M
L
XL
Program
Fee
Uniform
$
Total
____ CASH
____ CHECK
$
Parental/Guardian Contact Information (Please provide if registrant is under 18)
Emergency Contact:
Name: _________________________ Relationship: ________________Contact #_______________
Name: _________________________ Relationship: _________________ Contact # _____________
Allergies: _________________________________________________________________________
Health Condition: (e.g., Asthma, medications)____________________________________________
If none of the named contacts can be reached, what would you like N.Y.F.K Sport Association to do?
________________________________________________________________________________
Print Name: ______________________Signature: ____________________________ Date: _____________
NYFK Sport Center Parent/Guardian Consent Form
Last Name:____________________
Age (if minor):__________
First Name:____________________
Grade:__________
MI:_____
Gender:____
Phone (H):________________(C):_____________
Emergency Name:__________________________ Emergency #:________________
Mailing Address ________________________________________________________________ Zip________
PLEASE
READ CAREFULLY
AND SIGN BELOW TO INDICATE YOUR AGREEMENT.
City/State/Zip
_______________________________________________________________________
NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY
Please review and complete the sections below and sign in the space provided to indicate your agreement with all statements made in
such sections.
AUTHORIZATION AND RELEASE OF LIABILITY
I, the parent or guardian of the above-named child, authorize the participation of my child in the NYFK Sport Center (“NYFK”) Mixed
martial arts/kung fu program (“the Program”). I understand that my child’s and/or my participation in this program is voluntary. I further
understand and agree that my child’s participation in athletic and other activities of the Program necessarily involves the risk of injury
and even death from various causes, including but not limited to accidents, falls, strenuous and prolonged physical activity, dehydration,
illness, collision or dispute with other participants, weather related injuries, training area and equipment defects, and negligence of
instructors and referees. On behalf of my child, me, and my family, I assume these risks. In consideration of the privilege of my child’s
and/or my participation in the Program, and on behalf of my child and me as parent/guardian, I hereby release, discharge, hold
harmless and indemnify, and covenant not to sue, NYFK Sport Center, Instructors, and all of NYFK’s agents as to any and all claims of
my child, me and other family members for personal injuries suffered by my child and/or me, property damage, medical expenses, and
economic loss arising directly or indirectly out of my child’s and/or my participation in the Program, and any first aid, medical care or
treatment provided to my child and/or me in the event my child and/or I are injured or becomes ill while participating in Program
activities, and excepting claims that may not be released under applicable law.
This Release of Liability shall be as broadly construed as allowed by law to include all claims and rights that the child and/or I as a
participant, that I as parent/guardian, and that other family members may have. I am a legally responsible parent or guardian of my
child. If any provision of this Release of Liability is deemed invalid, the remaining provisions shall remain in full force and effect.
This Release of Liability shall be binding on me, my family, heirs, next of kin, legal representatives, beneficiaries, successors and
assigns.
I give permission for free use of my child’s and/or my name and picture in class photos, broadcasts, telecasts or written accounts for
any participation in a NYFK sponsored event.
MEDICAL CONDITIONS
I understand that participation in the Program may involve strenuous and prolonged physical activity. I agree that my child and/or I am
healthy and able to participate in the Program activities.
My signature below indicates that all information provided in this form is true and accurate, and that I fully agree to all statements made
on the form. Each responsible parent/guardian should sign.
Signature:______________________________
Signature:______________________________
Printed name:______________________________ Printed name:______________________________
Date: ____/____/____
Date: ____/____/____
If only one parent/guardian signs this form, the following must also be signed:
I affirm that this form was signed by only one parent/guardian because (1) I am the sole parent/guardian responsible for the care and
custody of the child due to death or incapacity of the other parent/guardian or court order, or (2) I have made a good faith effort to
obtain the signature from the other parent/guardian but have not been able to do so due to causes beyond my control, and I am not
aware of any reason that the other parent/guardian objects to the child’s participation in the Program.
Signature:______________________________
Printed name:______________________________
Date:____/____/____