Staten Island Jiu Jitsu & Karate Dojo Online Application For Membership Please Do Not Complete Application If You Are Not Serious About Becoming A Member.
Name Address City State Zip Home Phone Occupation Work Phone -- -- Email Date of Birth -- Sex Male Female
Name
Address City State Zip
Home Phone
Occupation
Work Phone
--
Email
Date of Birth
Sex
Present Rank & Style If None, Enter "None." 3 Character References Phone Numbers
Present Rank & Style If None, Enter "None."
3 Character References
Phone Numbers
Prior Martial Arts Experience.
If None, enter "None."
Have You Ever Been Arrested?
If Yes, Offense & Disposition If No, Enter "None."
How Did You Hear About Us?
Please Explain Why You Wish to Study With Us. What Do You Hope To Gain In Your Training? And Any Reason(s) For Potential Acceptance.
I understand that during the course of instruction, Instructors of the Goshindo Kempo Karate & Samurai Jiu Jitsu Assoc.; S.I. Jiu Jitsu & Karate Dojo and/or other members or authorized persons will be engaged in a course of conduct requiring physical contact; and I give full consent to such contact as is required by the training. The undersigned agrees the Assoc.; Dojo, its agents, members and employees, shall not be responsible for accidents or injuries of any kind, whether the same shall be caused by or attributable to their negligence or the negligence of any of them or otherwise.
The undersigned shall indemnify and same harmless the Assoc.; Dojo, its agents and employees, against all damage, loss or expense which they or any of them incur as a result of any claim or action which may at any time be made or instituted on behalf of the above named member including, without being limited to, any claim or action based upon the negligence of the Assoc.; Dojo, its agents, members or employees.
I, the undersigned, have completed this application truthfully. I understand that if, upon review of this application, it is revealed that I have made any false statements, my membership will be terminated without delay or refund. Submission of this application does not guarantee enrollment. The Goshindo Kempo Karate & Samurai Jiu Jitsu Assoc; S.I. Jiu Jitsu & Karate Dojo reserves the right to accept or decline applicants.