Registration Form

Date

Student Full Name(required)

Age of Student

Birth Date of Student(required)

Parent's Full Name (Primary Contact Person)(required)

Cell Phone(required)

Work Phone

Home Phone

Parent's Email(required)

Second Parent or Alternative Contact Person

Relation

Cell Phone

Work Phone

Home Phone

Emergency Contact(required)

Relationship

Emergency Phone

Second Student

Age of Second Student

Birth Date of Second Student

Address(required)

Apartment Number

ZIP Code

Preferred Class Day

Preferred Class Time

Previous Studies

Health Concerns

Comments and Other Concerns

Where did you learn about Tiger Strong? (required)

Under 18? (If yes, continue below)

As parent/guardian, I give my consent for my child(ren) to participate in the Tiger Strong NYC Karate Program. I recognize the possibility of injury in any martial arts program. I hereby waive and release Tiger Strong NYC, and any Officers, Employees, Agents and Assigns from any and against all claims of liability, including accidents or injury while on or about their premises. To the best of my knowledge, my child is in good physical condition and I have no knowledge of any physical condition, injury, or illness which would place my child at risk to participate in a martial arts class. This Acknowledgement of Risk and Waiver of Liability has been read, understood completely and signed voluntarily by the parent/legal guardian of the student(required)

I hereby authorize Tiger Strong NYC, its representatives and members the right to take photographs of me and to publish these photographs, along with use of my first name, to be use in any Tiger Strong NYC printed publications and/or website. I acknowledge that since my participation in publications and/or websites produced by Tiger Strong NYC is voluntary, I will receive no financial compensation. I further agree that my participation in any publication and/or website produced by Tiger Strong NYC confers upon me no rights of ownership whatsoever. I agree that Tiger Strong NYC may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. I release Tiger Strong NYC, its contractors and its members from liability for any claims by me or any third party in connection with my participation.(required)

Student's Name

Signature (Parent, if under 18)(required)

Location:

500 East 77th Street

New York, NY 10162

Ground floor Mall (behind Concierge Desk (ask for directions)

917-453-6503

Location:

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