Parent's Name

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Cell Phone *

Child's First Name

Child's Last Name

Child's Date of Birth

Participant represents being physically fit to take the prescribed program/activity. All use of the facilities shall be under taken at the sole risk of the participant. Action karate shall not be liable to the participant or their family for claims, damands, injuries, loss of property or acts of negligence. In consideration for being allowed to participate in Action Karate, the participant and their guardians hereby release, waive, and covenant not to sue Action Karate for any injuries which are sustained while on the premises.