ELITE MARTIAL ARTS : Jiu Jitsu, Kickboxing, Arnis, Tai Chi, Kids' Karate in Norwalk/Darien/Westport/Wilton, CT

Name:	Age:	DOB (mm/dd/yyyy):
Address:	City:	State: ZIP:
Annual Income: $	Marital Status: Single Married Divorced Widowed
Home Phone (with area code):	Work Phone (with area code): ext.	E-mail:

IF UNDER 21 YEARS OF AGE — NAME OF PARENT OR LEGAL GUARDIAN

Name:	Age:	DOB (mm/dd/yyyy):
Address:	City:	State: ZIP:
Home Phone (with area code):	Work Phone (with area code): ext.

IN CASE OF EMERGENCY, PLEASE CONTACT

Name:

Home Phone (with area code):

Work Phone (with area code):
ext.

Please describe prior Martial Arts training, if any:

Please list any health problems or physical limitations:

What are your reasons for taking Martial Arts? (Please check all that apply)

Self Defense	Self Confidence	Self Discipline	Lose Weight
Concentration	Physical Conditioning	Recreation	Other

WAIVER OF LIABILITY

Due to the nature of this class, we ask that you read the statement below. Please check "I Agree" to indicate that you accept all terms.

I, the undersigned, hereby release N. Bajra of Elite Martial Arts, LLC, and all persons associated with this in any capacity, from any liability due to injuries, etc., that I may incur as a result of my attendance and/or participation at the above-specified event. Furthermore, I hereby waive any compensation whatsoever for the use of pictures, movies, media coverage, etc., utilized by those associated with this event at any time. I clearly understand that fighting aspects of this sport and competition involve bodily contact. I have read, understand, and agree to abide by the rules associated with this event and assume all responsibility and any associated liability for infringement of such rules. Additionally, I am fully aware of my personal medical condition and hereby certify that I am mentally and physically fit to compete in said Karate School.

I Agree