REGISTRATION FORM

Name   Address       City     State      Zip     Home Phone     Work      Cell     Birthdate --pick one--JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember     ,      E-mail   Karate rank     Organization     PARENT OR GUARDIAN INFORMATION     Name   Home Phone     Work      Cell     EMERGENCY CONTACT INFORMATION     Name   Home Phone     Work      Cell   LEGAL WAIVER   I give permission for my child to participate in the "Karate-do" class held by Instructors Jairo Blanco and Marcia Blanco. I recognize that this activity has the potential for injury and acknowledge that, even with proper supervision, injuries can still occur. The nature of said injuries can range from light to severe, even resulting in total disability. I agree to hold Jairo Blanco, Marcia Blanco and the Fitness Edge totally harmless for any and all injuries my child may incur while participating in such activities and agree to not pursue any legal action against Jairo Blanco, Marcia Blanco, nor the Fitness Edge in the event that my child should sustian injury while participating in such activities. By signing below, I acknowledge that I have read, understand, and agree to abide by this Legal Waiver.   Date    ___/___/___ Parent/Guardian's Name    ____________________________________   Parent/Guardian's Signature    ______________________________________________ Call for updates on Registration Fee and Monthly Fee costs. Jairo Blanco. 802.825.5489