WC-KMAC AFFILIATION FORM / INDEMNITY

Student Information

Name: *

Surname: *

Student Date of Birth: *

Student I.D. No.: *

Cell Nr: *

Tel. (Work):

Residential Address:

Contactable Email Address (NOT UNIVERSITY E-MAIL): *

Parents Information

Parents Name & Surname:

Parents Cell:

Parents Email:

Parents Occupation:

Parents Residential Address:

Area Code:

Medical Aid Details

Medical Aid Name:

Medical Aid No.:

Doctor’s Name:

Doctor’s Tel. No.:

Main Member:

Allergies:

State any other Medical Condition:

Student Weight:

Student Height:

Any previous injury to be noted:

Details of Contact Person in Case of Emergency

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Tel. (Home):

Emergency Contact Tel. (Work):

Emergency Contact Cell No.:

Referral section. Please name the person who referred you (Optional):

Check to Agree:

I understand there may be a risk in the learning and practice of Martial Arts/Training by which may result in serious injury or even death.
I have further watched the art being taught and agree as a condition of membership, not to hold the WCKMAC instructors or students liable for any injury or death whatsoever, that I may sustain while practicing at WCKMAC from any cause whatsoever and I indemnify the aforementioned parties accordingly.
I also agree to abide by the rules and regulations of WCKMAC
I also acknowledge that I have been informed of the membership fee structure and payment thereof. I am also aware of the late payment penalties. I agree to the fee structure and the payment thereof.
I furthermore acknowledge that any personal belongings of students that are used, left or stored on the premises are for the student’s own risk and I indemnify WCKMAC of any responsibility.
I understand that any photos or videos taken during class may or may not be used by the discretion of the instructor.

Signature of Student: *

Signature Date:

Signature of Parent/Guardian if student is under 18: