United States Karate & Jiu-Jitsu Association • Vero Beach Karate Association MEMBERSHIP APPLICATION (Please Print) Date: ________________________ Name: _______________________________________ Birth Date: ___________________ Age: _______ Address:____________________________________________________________________________ No. Street City State Zip Code Height: ________ Weight: ________ Sex: __ Male__ Female Occupation (if applicable):______________ Home phone: _______________________ Work phone: ___________________ This will let you opt in to our text message notification service. Mobile Phone: _____________________ Carrier _____________ ie. AT&T, Verizon, Sprint, etc… E-mail address: _______________________________________________ May we contact you by e-mail? yes/no School (If applicable): __________________________________________________ Grade: _____________ What prompted you to contact/visit our school? (Check all which apply.) _____Internet _____Sign _____VBKA Website _____Friend _____Yellow Pages _____ Facebook _____ Other: ______________________________ Parent Information (If applicable) Father’s Name: ____________________________ Mother’s Name: ___________________________ Occupation: _____________________________ Occupation:_________________________ Home Phone: ___________________________ Home Phone:________________________ Work Phone: ____________________________ Work Phone:________________________ Cell Phone: _____________________________ Cell Phone: _________________________ Child resides with: _____ Both parents _____ Mother/Step-father _____ Father/Step-mother _____ Other Person responsible for dues: ____________________________Relationship to Student:_________________ Medical Information/Special Needs: ___________________________________________________________ Release In consideration of United States Karate & Jiu-Jitsu Association/Vero Beach Karate Association providing me/my child/family the opportunity to train in Karate, Jiu-Jitsu, and all Martial Arts related activities upon the premises or property of the Karate and Jui-Jitsu school, the undersigned hereby assumes any and all risks of injury and hereby waives and does hereby release and discharge United States Karate & Jiu-Jitsu Association/Vero Beach Karate Association, its officers, agents, and employees, from all liability to the undersigned, his employer assigns, and personal representatives for all loss or damage, and any claim for damage therefore, on account of injury or other casualty to the person or property of or in the possession or control of the Karate Association, its officers, agents, employees, licensees, or by fellow students while the undersigned and/or such property is upon the premises of United States Karate & Jiu-Jitsu Association/Vero Beach Karate Association, or while the undersigned is a participant in any exhibition, demonstration, contest, or association sponsored activity or event. It is further understood by the undersigned that Karate, Jiu-Jitsu, and all Martial Arts are sports involving physical combat and therefore the undersigned hereby assumes the risk of any injury which might be sustained while involved in activities of the United States Karate & Jiu-Jitsu Association/Vero Beach Karate Association. I hereby authorize and consent to the use of his/her or my visual image by United States Karate & Jiu-Jitsu Association/Vero Beach Karate Association for appropriate purposes, including but not limited to: still photography, videotape, electronic and print publications, websites, and social media. I give this consent with no claim for payment. For Office Use Only: Class Attending: ______________________ __________________________________________________________ Instructor: ___________________________ Student Signature/Parent or Guardian if student is under 18 years of age. Location: ____________________________ United States Karate & Jiu-Jitsu Association • Vero Beach Karate Association MEMBERSHIP APPLICATION 2015 9th Street SW, Suite C&D Vero Beach, Florida 32962 (772) 567-9899 [email protected] Understanding that the daily updates both nationally and globally regarding the COVID-19 outbreak can be unnerving, the management of the Vero Beach Karate Association would like you to know we have a protocol in place with our instructors and staff to be as proactive as possible during this time. We are monitoring information from the CDC and Florida Department of Health. We will be reminding our students about basic personal hygiene practices and we will continue to keep our classrooms clean and have hand wipes/hand sanitizer available the minute they walk into class. In the meantime, we do want to appeal to you about yours and your children's health. If you or your child is sick, please DO NOT come to class until such a time as everyone is symptom free. If you have been in contact with any confirmed COVID-19 patients or travel to any regions affected by the virus, please wait 14 days before returning to classes. The health of our students and our instructors must be a priority. Thank you for your cooperation. WAIVER OF LIABILITY I, ______________________________________________ a student or the parent/guardian of ________________________________________________ hold harmless the United States Karate & Jiu Jitsu Association (Vero Beach Karate Association) and any other associated entity from any liability for any illness that may occur while participating in a class at any Vero Beach Karate Association location during this Coronavirus outbreak. I understand that I need to either stay at home or keep my child home if I/they exhibit any flu like symptoms, to keep everyone safe and healthy. Date: _____________________________ Signature of adult student or parent/guardian: ______________________________________________________________________ Printed Name: __________________________________________________________ .