Dr. Lee's Academy Of Martial &Healing Arts

5 East Scott Street  Riverside New Jersey 08075 USA

Tel. (856) 824-0085 E-mail:hsilee102@yahoo.com 

Application

NAME:________________________________________AGE:______ SEX: Male__ Female_______

Please Print    (Last)                                (First)

ADDRESS:__________________________________________________________________________

                 (Street)                   (City, Town, State)                    (Zip Code)

DATE OF BIRTH:________HOME PHONE #______________WORK PHONE #_______________

CELL PHONE #_______________________ E-MAIL: _____________________________________

NAME OF PARENT OR GUARDIAN (If Applicable) _____________________________________  

         I, the undersigned, hereby apply to Dr. Lee's Academy Of Martial & Healing Arts for a course of instruction in self-defense (Of my chosen Art)

in consideration in which I agree to pay said school the non-refundable instruction fee in the sum of $________ payable as follows:­_________________

       I further agree & understand that the course for which I or my child or ward is making application involves inherent risks of accidental physical injury.

I therefore agree to assume such risk of injury that may occur to myself, my child, or my ward, and hereby relieve and agree to hold harmless and to indemnify

from any claim on account such injury sustained by me, my child, or my ward, Dr. Lee's Academy Of Martial & Healing Arts, its owners, its officials,

its instructors,  agents or employees from any intentional, willful act, or negligence.

        I further agree to abide by the rules and regulations of the school at all times while on the school premises or at any sanctioned contest of martial arts.

I also understand that the school assumes no responsibility for lost or damaged personal property.

       I further understand that the enrollment in the school carries no guarantee of any belt or sash rank or level to be attained.

       After completion of my course, I agree to refrain from instructing any martial art without written permission of this school, within a radius of 45 miles,

for one year.

(Date of Application)___________________ (Signature of Student)_____________________________________________

 __________________________________         ____________________________________________________________

Print                                                                         Signature of Parent or Guardian  (if student is not 18 years of age)