Join the Aikido Network

Membership Application Form

Name:
Email:
Address:
Telephone Number:  
Home:
Business:
Date of Birth:
Health Card Number:
Character Reference
Reference Phone Number
Previous Martial Art Experience  
Club
Style
Belt

What would you like to learn from Aikido or Jiu-jitsu?

  1. Gain insight into its principles
  2. Physical Fitness/ Recreational
  3. Practical Self- protection
  4. Other

How did you become aware of our school?

  1. Word of mouth
  2. Signs/Location
  3. Yellow pages / Workshops

Medical History

Please indicate any health challenges (e.g. heart, allergies, skin condition, previous injuries etc.):

  Condition Date of Occurence
1
2
3

Informed Consent Agreement

Thank you for choosing to use our services. We request your understanding and co-operation in maintaining both your and our safety and health by reading and signing the following consent agreement.

I declare that I intend to use some or all of the activities, facilities, programs, and services offered by Aikido Network and I understand that each person (myself included) has a different capacity for participating in such activities, facilities, programs and services. I am aware that all activities, services and programs offered are either educational, recreational, or self-directed in nature. I assume full responsibility during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive.

I understand that part of the risk involved in undertaking any activity or program is relative to my own state of fitness or health (physical, mental or emotional) and the awareness, care and skill with which I conduct myself in that activity or program. I acknowledge that my choice to participate in any activity, service and program of Aikido Network brings with it the assumption by me of those risks or results stemming from this/these choice(s) and the fitness, health, awareness, care and skill that I possess and use. In addition, I understand that I am free to withdraw from, reduce or modify my involvement in any program activity and I realize that I should do so upon recognition of any signs of transient lightheadedness, fainting, chest discomfort, leg cramps, nausea, etc.

In addition, I acknowledge that I have inquired about of the nature of any activity, program or services that I am not completely familiar with and I have been informed of any inherent risks.

By entering my name, I declare that I have read, understood and agree to the contents of this INFORMED CONSENT AGREEMENT in its entirety.

Aikido Network Copyright 2006