Uechi-Ryu Karate Club

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Uechi-Ryu Karate Club

Student Registration and Waiver

(all information remains confidential)
Last Name: ____________________________ Student’s First Name: ___________________________________________
DOB: ________/_______/________ Age: _______ Homeroom Teacher:_________________________M/F: __________
Address: ____________________________________City: _______________________State: __________ Zip: _________
Mobile/Cell Phone: (________)_________-__________


Does your child have any health and/or behavioral issues/concerns?_________________________________________

I hereby give permission for ________________________________ to participate in the Uechi-Ryu Karate Club at Folger McKinsey Elementary. I understand that my child will go directly to their first class upon dismissal from the activity. While all reasonable precautions will be taken to assure the safety of my child and to prevent any injuries from occurring, I will not hold the instructor, Ellicott City Fitness and Karate, nor the PTO and its officers/members liable for any incident that may occur. My child and I also understand that if, after one warning, any student is unable to maintain appropriate behavior in the club that the student will not be allowed to attend the remaining sessions scheduled.

Parents will be notified at the time of the warning and before their child is removed from class. Refunds will not be issued for any student removed for these reasons.

Parent Print:___________________________________Signature____________________________ Date: ___________

REGISTRATION DEADLINE is Friday, September 14, 2012 Classes begin Tuesday, September 18 or Wednesday, September 19, depending on grade level
Return this form and your payment for $109 (check payable to: K and M Holdings) in an envelope to the front office. Mark the envelope: PTO Karate Club. Please be sure to email peace@greentara.com first to reserve your spot!

  • Questions? Contact…Contact Instructor Tara Benson 410-432-6139

or email peace@greentara.com
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