Chalmers Massage, Yoga, Tai Chi and Spencer Goju-Ryu Karate

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SPENCER GOJU-KAI KARATE-DO

Name:________________________________

Address: ______________________________

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 Spencer 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: ______

IF UNDER 18
Parent or guardian signature:

Signature: _____________________________ Date: ______

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