PARTICIPANT INFORMATION:

First Name: Last Name:

Date of Birth (mm/dd/yyyy): Gender: Male   Female

Student Height: Weight: Clothing Size:

HOME ADDRESS:

Address Street: Apt #:

City: State: Zip Code:

Telephone (incl. area code):

PARENT OR GUARDIAN INFORMATION:

Guardian’s Name:  Relationship:

Mobile Telephone:

E-Mail Address :

School attending:   Highland Ranch    Rolling Hills    Shoal Creek    Stone Ranch

Current Class/Grade:

School Contact Name:

            School Contact's Position:   Counselor   Teacher  

After the class I will be:

    My child will be attending ESS

    My child will be picked up by 

    My child will be walking home

Please supply if your child has outdoor allergies:

By entering the date below and clicking the Submit Application button, I indicate that I have read and agree by participating in Martial Arts that my child may risk bodily injury and knowingly and freely assume all risk for my child. I release and hold harmless and nor hold legally responsible the PUSD, TEMAS or MANNA’S MARTIAL ARTS with respect to any injury except that which results from negligence or willful misconduct.

I have made my child aware of the safety rules of the school and give my permission for him/her to participate in this TEMAS After School Karate Enrichment Program.

Martial arts (karate) classes are being instructed and donated to TEMAS by Manna's Martial Arts and taught by Certified Instructors located at: 12285B World Trade Drive, San Diego CA 92128. www.manna.us. All fees paid to TEMAS are souly used in direct operation and by TEMAS, a non profit 'For the futher enhancement of the arts.'

By entering the date below and clicking on the "submit Application" button below, I am declaring that all of the information provided on this form is accurate and true, and that I agree to the terms and conditions of this TEMAS Outreach After School Karate Program.

Guardian (as named above)

Date (mm/dd/yyyy):

     

Please fill in ALL required fields indicated with an ().