Student Information

Please fill out general information about the student.


Previous Experience

If the student has previous experience, please fill out the section below.


Emergency Contact Information

Please provide contact information for the parent or guardian.


Health and Goals Information

Please let us know of any health or medical conditions that may impact training.


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Has the student been hospitalized in the last 5 years?
Does the student have any medical conditions we need to be aware of?
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General Agreement and Release

It is understood that the training, instructions, test, and/or lessons which I have herein before registered for and agreed upon, involve STRENUOUS PHYSICAL ACTIVITY, AND MAY RESULT IN PERSONAL INJURY.  The aforementioned party, whose signature is also hereinafter affixed, hereby avers and represents that he or she has no knowledge of any physical condition which would render it dangerous and/or hazardous to said party's health or safety for him or her to participate in such training, instructions, and/or lessons and PROMISES TO NOTIFY AMKOR KARATE OF COATESVILLE, INC., COATESVILLE, PENNSYLVANIA, ITS AGENTS AND/OR INSTRUCTORS, IMMEDIATELY, IN WRITING SHOULD ANY SUCH CONDITION DEVELOP.  It is understood that this written notification of such physical conditions shall be delivered, in person, to the Instructor (s) at Amkor Karate of Coatesville, Inc. Coatesville, Pennsylvania before the next lesson or workout which follows discovery and/or awareness by the undersigned of any change in his or her physical condition.  Upon receipt of such notification, the instructor (s) reserve the right to terminate and/or discontinue and/or postpone further lessons or workouts for said individual.

Recognizing, and being fully aware of all the facts, assertions, and representations, herein before mentioned, the party whose signature is affixed below, individually and for his heirs, executors, administrators, successors, and/or assigns EXPRESSLY ASSUMES ALL RISK OF INJURY RESULTING DIRECTLY OR INDIRECTLY FROM THE TRAINING, INSTRUCTIONS, TESTS, TOURNAMENTS, AND OR LESSONS IN KARATE received at Amkor Karate of Coatesville, Inc. and/or affiliated schools which said party may enter.

Moreover, in consideration of receiving training, instructions, and/or lessons, at/by Amkor Karate of Coatesville, Inc. said party, whose signature is affixed below, individually and for his or her heirs, executors, administrators, successors, and/or assigns, does hereby waive, release, and forever discharge any and all rights and claims for any damages or losses which said party may have, or which may accrue to said party against Amkor Karate of Coatesville, Inc. and/or its instructors, officers, agents, representatives, successors, affiliated schools, facilities used for tests, and/or assigns, and against its students, for any and all causes which may arise in connection with the training, instructions, tests, tournaments, and/or lessons in Karate received at Amkor Karate of Coatesville, Inc.


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