Ernie Reyes` World of Martial Arts

ErnieReyes'WorldMartialArts
Campbell
YMCACampInformationSheet
First Name: ______________________ Last Name: ______________________
Date of Birth: ________________ Age: _________ Sex: ____ M ____ F
Home Phone: ( ____ ) _____- ______ Cell Phone: ( ____ ) _____- ______
Address: _________________________________________ Apt. #: ________
City: _________________ Zip Code: __________
Father's Name: ______________________ Cell Phone: ( ____ ) _____- ______
Email: ________________________________________________
Mother's Name: ______________________ Cell Phone: ( ____ ) _____- ______
Email: ________________________________________________
Is the new student/guest in good health and with no physical problems?
_____ Yes
_____ No, please explain: _____________________________________________
The undersigned person or parent/guardian releases Ernie Reyes' West Coast Tae Kwon Do Karate,
Inc. froThe undersigned person or parent/guardian releases Ernie Reyes' West Coast Tae Kwon Do
Karate, Inc., all instructors and all other students of Ernie Reyes' West Coast Tae Kwon Do Karate,
Inc. from any and all liabilities for any type of injuries or loss sustained while at Ernie Reyes' West
Coast Tae Kwon Do Karate, Inc. The undersigned also states that he/she is in good physical
condition. In the event of an emergency, I hereby authorize any licensed medical personnel to
perform any accepted medical procedure deemed necessary and agree to bear the expense
of any such treatment.
m
Parent's Signature: _____________________________
Date: __________
In case of Emergency, call _____________ Home Phone: ( ____ ) _____- ______
90 N. San Tomas Aquino Rd. Campbell, CA 95008 408-374-1177