Membership Application

PeopleSafe Online Membership Application
Adult Members Only

Membership Type

New     Renewal

 
Personal Information
First Name
Last Name
Street Address
City
State
Zip Code
Home Phone No.
Email Address
Date of Birth
Sex male     female
Occupation
Work Phone No.
Emergency Contact
Phone

Character Reference 1
Phone
Character Reference 2
Phone
Do you have any physical or emotional impairments? yes     no
If yes, describe
Have you ever been charged or convicted of a felony?? yes     no
If yes, offense & disposition
Are you on any medications? yes     no
If yes, describe
  
Martial Arts Experience
Last Dojo you belonged to
Instructor
Style Rank Date  Dojo
Please explain why you 
selected to study at our dojo.
How did you hear about us?
word of mouth
yellow pages
saw sign
referred by a member
Was a prior member
Internet website
Note:  For recognition of rank, documentation in English must be provided.

 

Make checks or money orders payable to: Phil 
Rasmussen 
and
mail to:
PeopleSafe  
521 Starmount Lane
Hendersonville, NC 28791

 

GENERAL RELEASE OF RESPONSIBILITY

I Certify that I have been made aware of potential hazard involved in martial arts and training for self defense. I am physically fit and have no medical condition which would preclude me from participation in these activities. I understand that during the course of instruction, PeopleSafe Instructors 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 shall indemnify and same harmless PeopleSafe, 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 PeopleSafe, its agents, members or employees.

I promise to uphold the principals, ideals and regulations of PeopleSafe. I acknowledge that my membership is voluntary and subject to review by PeopleSafe

    By this check, I certify, to the best of my knowledge, that the information in this application is true and accurate.  I understand that if, upon review of this application, or anytime thereafter, it is revealed that I have made any false statements, my membership will be terminated without delay or refund. PeopleSafe reserves the right to accept or decline applicants. I understand that I must sign this application before being allowed to participate in any PeopleSafe activities.  

Further, I understand that by submitting this information via electronic transmission that I acknowledge the above statement of certification in lieu of a signature.

Copyright 2003 PeopleSafe  All rights reserved.