CHALMERS GOJU-KAI KARATE-DO

Application Form

Name:________________________________

Address: ______________________________

Email:_________________________________

Date of Birth: __________

Phone___________ Cell Phone__________________________

Previous Martial Arts training: ____________

How Long? _____________ Rank: ________

Physical concerns?_____

Describe Briefly:_______________________________________

I understand that there is a risk of personal injury with the practice of any martial art. I
waive and release Steven or Shirley Chalmers from any liability or illness incurred while
participating in any activities provided by the Chalmers Goju-Kai Karate-Do. The applicant is
 in good physical health and able to participate in rigorous physical activity. I have read and
understand this release and waiver prior to signing.

Signature: _____________________________ Date: ______

Signature: _____________________________ Date: ______