Registration Form 

Student Name 

Registration Location 
Day of week Time of Lesson 
Amount paid Recieved GI 

Paid by cash / cheque GI Size 

Notes 

Please PrintPlease PrintPlease Print 
Office Use OnlyOffice Use OnlyOffice Use Only 
Age Birthday 
Martial Art Experience (please circle)(please circle) -NONENONE 1-3 years 3 years + 
Parents / Guardian NameParents / Guardian Name 
Primary Contact Name 
Mailing Address 

City Postal Code 
Primary 

Emergency 
Contact Number 

Number 
Primary Contact 
Email Address 

Physical Health (please list allergies and all health related problems):Physical Health (please list allergies and all health related problems):Physical Health (please list allergies and all health related problems):Physical Health (please list allergies and all health related problems): 

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RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENTRELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT:RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT: 


IN CONSIDERATION CONSIDERATION OF NicoleNicole Poirier and TOP Karate, my child, child,child, being allowed to participateparticipate in karate andand relatedrelated events andand activities, the 
undersigned acknowledges, appreciates, and agrees that:undersigned acknowledges, appreciates, and agrees that:undersigned acknowledges, appreciates, and agrees that:undersigned acknowledges, appreciates, and agrees that: 

The risk of injury to to my child child from the activities activities involved in these programsprograms is significant, significant, including including the potential for permanent permanent disability disability and death, 
and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 

1) FOR MYSELF, SPOUSE, SPOUSE,SPOUSE, AND CHILD, I KNOWINGLY KNOWINGLY AND FREELY FREELYFREELY ASSUME ALL SUCH SUCH RISKS, both known known and and unknown, EVEN EVEN IF ARISING 
FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and,FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and, 

2) I willingly agree to comply comply with the program's program's stated and customary customarycustomary terms and conditions conditionsconditions for participation. If I observe observe any unusual unusual significant 
concern in my child's child's readiness readiness for participation participation and/or in the program programprogram itself, I will remove remove my child child from the participation participationparticipation and bring such attention of 
the nearest coach immediately; and,the nearest coach immediately; and,the nearest coach immediately; and, 

3) I myself, my spouse, spouse, my my child, and on behalf behalf of my/our heirs, assigns,assigns, personal representatives representativesrepresentatives and next of kin,kin, HEREBY HEREBY RELEASE RELEASE AND HOLD 
HARMLESS TOP Karate Karate its its members, WITH RESPECT TO ANY ANDAND ALL INJURY, DISABILITY, DISABILITY,DISABILITY, DEATH, or loss loss or damage damage to person person or property 
incident to my child's child's involvement involvement or participation participation in these programs, programs,programs, WHETHER ARISING ARISING FROM THE NEGLIGENCE NEGLIGENCENEGLIGENCE OF THE RELEASEES OR 
OTHERWISE, to the fullest extent permitted by law.OTHERWISE, to the fullest extent permitted by law.OTHERWISE, to the fullest extent permitted by law.OTHERWISE, to the fullest extent permitted by law. 

4) I, for myself, my spouse,spouse, my child, and on on behalf of my/our heirs, heirs,heirs, assigns, personal representativesrepresentatives and next next of kin, kin, HEREBY INDEMNIFYINDEMNIFY AND 
HOLD HARMLESS all the above above Releasees from from any and all liabilities liabilities incident to my involvement involvementinvolvement or participation in in these these programs, EVEN EVEN IF ARISING 
FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.FROM THEIR NEGLIGENCE, to the fullest extent permitted by law. 

5) I also grant TOP Karate and their members members the right to photograph photographphotograph and/or videotape me and and my child or ward ward and and further to display, display, use and/or 
otherwise exploit my my or my my child's or ward's name, name, face, likeness, voice,voice, and appearance appearance forever forever and throughout thethe world, world, in all media, media, whether now 
known or hereafter devised,devised, throughout the universe universe in perpetuity perpetuity (including,(including, without limitation, limitation,limitation, in online webcasts, webcasts, on on television, in motion pictures, 
films, newspapers, and magazines) magazines) and in all forms including, without withoutwithout limitation, digitized digitized images, images, whether for advertising, advertising,advertising, publicity, publicity, or promotional 
purposes, including, including, without without limitation, publications publications of TOP Karate, Karate, without without compensation, compensation, reservation reservation or limitation, limitation, or further further approval, approval, and I agree to 
indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use.indemnify and hold harmless TOP Karate for any Claims associated with such grant and right to use. 

SCHEDULE PAYMENT TERMSSCHEDULE PAYMENT TERMSSCHEDULE PAYMENT TERMSSCHEDULE PAYMENT TERMS 

Full Season RegistrationFull Season Registration 

All students registeredregistered for aa full season must be:be: a) paid in full priorpriorto the season start oror by thethe date of the first first scheduledscheduled class; oror b) must submit 
three (3) post-datedpost-dated chequescheques (dated for the 1st class and the 1st of thethethe month for January andand April;April; please see PricePrice List) List) submitted priorprior to the season 
start or by the datedate of the the first scheduled class; class; c) must submit tenten (10) post-dated cheques chequescheques prior to the season season start start or by the the date of the first 
scheduled class. StudentsStudents registeredregistered for a Full Full Season that have not not mademade payment as indicated indicatedindicated above may be asked asked to to leave class until until payment has 
been made. 

Monthly RegistrationMonthly Registration 

All students registered registered on a month-by-month month-by-month basis must submit paymentpayment by the first scheduledscheduledscheduled class. Students Students registered registered on a month-by-month 
basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made.basis that have not made payment as indicated above may be asked to leave class until payment has been made. 

Drop-in AttendanceDrop-in Attendance 

Students who drop drop in for oneone (1) class session session are required to make makemake payment prior to the start start of the class. Drop-in Drop-in students that that have not made 
payment as indicated above may be asked to leave class until payment has been made.payment as indicated above may be asked to leave class until payment has been made.payment as indicated above may be asked to leave class until payment has been made.payment as indicated above may be asked to leave class until payment has been made.payment as indicated above may be asked to leave class until payment has been made.payment as indicated above may be asked to leave class until payment has been made. 

Cancellation Policy 

One (1) month written written notice notice is required to cancel cancel a membership membership (email (email to nicole@topkarate.ca nicole@topkarate.canicole@topkarate.ca is acceptable). acceptable). AnyAny cheque(s) that that has not been 
cashed at time of notification notificationnotification will be destroyed. destroyed. There is no cash reimbursement, reimbursement,reimbursement, however however unused unused balance will be be applied applied as a credit credit toward the next 
season. All credits willwill expire expire one year from the the date of the last class classclass attended. All credits credits are non-transferrable and must must be used by the registered 
student to which it was originally applied.student to which it was originally applied.student to which it was originally applied. 

I HAVE READ THIS THIS RELEASE RELEASE OF LIABILITY LIABILITY AND ASSUMPTION ASSUMPTIONASSUMPTION OF RISK AGREEMENT, AGREEMENT, FULLY UNDERSTAND UNDERSTAND ITS TERMS, TERMS, UNDERSTAND 
THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 
I HAVE READ AND AND UNDERSTOOD UNDERSTOOD THE PAYMENT PAYMENT TERMS ANDAND AGREE TO FULLY FULLY COMPLY COMPLY WITH ONE ONE (1) (1) PAYMENT SCHEDULE AS 
OUTLINED ABOVE.OUTLINED ABOVE. 


Signed this day of 20 at 
Parent or guardianParent or guardianParent or guardian (for under 19 years)(for under 19 years) 
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