Dojo Membership Application

Membership Application

PeopleSafe^Ž 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^Ž
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^ŽInstructors 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^Ž, 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^Ž, its agents, members or employees.

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

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^Ž reserves the right to accept or decline applicants. I understand that I must sign this application before being allowed to participate in any PeopleSafe^Ž 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.