First and Last Name *Address *Telephone *Email *Emergency Contact Person and Contact Details *Alternative Emergency Contact Person and Contact Details *Doctor Information *Hospital Insurance NumberPrevious InjuriesMedications, Allergies or Other ConsiderationsDoes the student know how to administer their own medications (if applicable)School Information (If applicable)Is this student allowed to go home alone?Yes the student can go home alone without supervisionNo, the student is not permitted to go home aloneIf the student isn't allowed to go home alone, who is the guardian?Agreement *In consideration of my participation in this program, I hereby waive, release and discharge any and all claims for damages I may have or which may hereafter accrue to me, as a result of my participation in this activity. This release is intended to discharge in advance the instructors, promoters, sponsors, organizers, project managers, of this activity and any involved public school or public entity and respective agents and employees including but not limited to the Southwest Budokan, their employees, agents and directors, from and against any and all liability which may arise out of negligence or carelessness on the parts of the persons or entities mentioned above. Media WaiverI understant that this program may be photographed, videotaped and the Southwest Budokan does have my permission to use the photographs, videotapes and/or audiotapes for the purpose of promoting the work and mission of the organization. I have carefully read this agreement and fully understand its contents. I am aware that this is a relase from liability regarding the parties listed above and an assumption of risk by myself. Authorization: By Entering your name below you are signing this form and agree to submit this information to the SWM Budokan for the purposes of registering for a martial arts program. *FirstLastPhoneSubmit