New Student
Registration &
Agreement

If this is your first time registering for a class with White Dragon KungFu,
attend your first class for FREE!

Student Name

First Name

Last Name

Phone Number (if 18+)

Email (if 18+)

Parent/Guardian 1 Name (if student under 18)

First Name

Last Name

Parent/Guardian 1 Phone

Parent/Guardian 1 Email

Parent/Guardian 2 Name (Optional)

First Name

Last Name

Parent/Guardian 2 Phone (Optional)

Parent/Guardian 2 Email (Optional)

Course You are Registering For

Student's Date of Birth

YYYY

Physical Address 1

Physical Address 2 (Optional)

Emergency Contact 1 Name

First Name

Last Name

Emergency Contact 1 Phone Number

Emergency Contact 2 Name (Optional)

First Name

Last Name

Emergency Contact 2 Phone Number (Optional)

Does the student have any medical or behavioral health issues we should be aware of?

Anything else we should know (e.g. pick up info)?

AGREEMENT: Terms & Conditions

WARRANTY OF PHYSICAL FITNESS: Student acknowledges and warrant's that member is in good physical condition and that member has no disability, impairment or ailment preventing member from engaging in active or passive exercise or that which will be detrimental to member' s health, safety, comfort or physical condition by so engaging or participating. Member further acknowledges that member has been advised by school personnel to see members’ personal physician before engaging in kungfu and self-defense program, or any condition has been announced in writing to the School members.

Adult Student or Parent/Guardian INITIAL HERE

ASSUMPTION OF RISK AND WAIVER OF LIABILITY: Use of any of the facilities shall be undertaken at the sole risk of the member. The facility shall not be liable for any damages to any person or property arising out of the member's use of the facility, equipment, or instruction. Member does hereby release and discharge Kimberly Bowen, Columbia City Fitness, Junhong Kungfu Club, the hosting facility, and her instructors from any and all claims, demands or actions from classes, equipment and employees, including without limitation any claim for personal injury, damage, or loss of property resulting from or arising out of the acts or any other person at the School. It is understood that kung fu and the martial arts are contact sports and that there are possible risks of bodily injury involved in their training.

Adult Student or Parent/Guardian INITIAL HERE

FAILURE TO ATTEND CLASSES OR USE FACILITIES: Failure of member to attend classes or use School facilities in no way relieves member of member's obligations to pay, and any refunds are at the sole discretion of Sifu Kimberly Bowen.

Adult Student or Parent/Guardians INITIAL HERE

MEDICAL TREATMENT: I hereby authorize simple First Aid or CPR, and consent to Ambulance Transportation, and any X-ray's, Medical, or Surgical Diagnosis that may be required in the event of an injury.

Adult Student or Parent/Guardians INITIAL HERE

PHOTO RELEASE: I hereby agree to the photography of student and use of the photos for marketing purposes.

Adult Student or Parent/Guardians INITIAL HERE

COMMUNITY HEALTH: I agree to abide by the State, County, and local public health laws and guidelines which may include wearing of a mask, keeping a safe distance, and cleaning hands. I agree that I will not attend class if I have symptoms of illness or have been exposed to anyone with symptoms of illness in the last 48 hours and that I will notify the instructor if I have symptoms or have been exposed.

Adult Student or Parent/Guardians INITIAL HERE

Signature (Type Name)

If under age 18 release and consent must be signed by parent/guardian.

New StudentRegistration &Agreement

New Student
Registration &
Agreement