Hello, if you're on this page we either sent you a link to this page to not only help us learn a little bit about you but also supply us with important contact and emergency contact information. Every space must be filled out to complete the form. One form must be filled out for each child.

Student Name *
Student Name
Parent/Guardian Name
Parent/Guardian Name
Required if under the age of 18 yrs.
Address *
Home Phone *
Home Phone
Mobile Phone *
Mobile Phone
Work Phone *
Work Phone
We will not call you at work unless it's an emergency.
Emergency Phone *
Emergency Phone
If no, you can enter "N/A"
What benefits are you looking for yourself or your child? *
If no, you can enter "N/A"
Please enter brief description of what you would like to get out of martial arts.
Release and Waiver of Liability We, the student & guarantor, if applicable, on behalf of ourselves, members of our family, our heirs, executors, administrators and assigns, hereby forever release, discharge and hold harmless, Peaceful Warrior Dojo, representatives and agents for any injury, loss, or damage to my person or property howsoever caused, arising out of or in connection with my taking part in martial arts classes and activities and notwithstanding that the same may have been contributed to or occasioned by the negligence of Peaceful Warrior Dojo Representatives or agents. Please Note: participants must supply their own protective equipment. *
By clicking below you agree to the above terms.